Cancer Screening Behaviors and Health Literacy Levels of Women aged 30 and over

doi:10.21203/rs.3.rs-2508078/v1

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Cancer Screening Behaviors and Health Literacy Levels of Women aged 30 and over

https://doi.org/10.21203/rs.3.rs-2508078/v1

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Purpose

This study aimed to determine the cancer screening behaviors of women over 30 and the factors affecting them during the Covid-19 pandemic.

Methods

This cross-sectional study was conducted with 301 women aged 30 and over in Edirne, the border province in northwest Turkey. Study data were collected with the Personal Information Form and Turkiye Health Literacy Scale-32 (THL-32).

Results

The mean age of the participants was 43.66 ± 9.02; 65.1% were between the ages of 30–49, and 85% were married. 74.8% of the participants did not have a screening test during the pandemic. Women underwent breast examination (32.2%), pap smear test (21.9%), and fecal occult blood test (19.9%), respectively, with an attending physician. The mean health literacy score of the participants was 28.18 ± 7.55, and the majority (80.7%) were in the category of inadequate-limited health literacy. The mean health literacy score and breast cancer screening were statistically significant (p < 0.05).

Conclusion

The study group's participation status and health literacy levels in cancer screening tests were low. The COVID-19 pandemic period negatively affected the individuals' participation in screening tests.

Covid-19

women

Cancer screening

Health Literacy

According to the World Health Organization-International Agency for Research on Cancer (IARC) 2020 data, the cancer burden in the world is estimated to increase when the rates reported as 19.3 million new cases and 10 million deaths are compared with the rates of 18.1 million cases and 9.6 million deaths in 2018. According to 2020 statistics, with 2.3 million new cases, female breast cancer (11.7%) surpassed lung cancer (11.4%) as the most commonly diagnosed cancer, followed by lung, colorectal (10.0%), prostate (7.3%), and stomach (5.6%) cancers [1]. Breast cancer is the most frequently diagnosed cancer in women and is the leading cause of cancer-related deaths. Breast cancer is followed by lung cancer and colorectal cancer in mortality rates. Moreover, it is predicted that cancer, the second most common cause of death worldwide, will increase rapidly and take first place in the next decade [2].

Cancer is a challenging disease to fight in all aspects. However, it is a fact that the most important mechanism in cancer control is disease prevention as much as possible and early diagnosis for those who developed it [3]. Well-planned, multidisciplinary, scientific, and cost-effective protection programs should be developed to control the disease. Treatment and recovery of people who have the disease and who have developed it at an early stage with screening programs are more straightforward and less costly than people with advanced disease [2]. Cancer screening in Turkiye is done as opportunistic and community screening. Community-based cancer screening is carried out by Cancer Early Diagnosis Screening and Training Centers (KETEM). Opportunistic screenings are done to people who apply to second and third-level hospitals. Based on the principle of "Early diagnosis saves lives!" KETEMs conduct screening programs for breast, cervix, and colorectal cancers and aim to save patients' lives by early diagnosis.⁴ In Turkiye, breast, cervix, and colorectal cancer screening, which can be diagnosed early, are performed within the scope of the National Cancer Control Program, which has been carried out since 2008. It is recommended to perform mammography every two years for women aged 40–69 for breast cancer screening, pap-smear and HPV-DNA test every five years for women aged 30–65 for cervical cancer screening, fecal occult blood test every two years for men and women aged 50–70 for colon cancer screening and colonoscopy every ten years [4].

One of the essential factors affecting individuals' participation in cancer screening programs is their health literacy levels. Health literacy is defined as the individual's personal, cognitive and social skills that determine his/her ability to access, understand and use the information to improve and protect his/her health. Although health literacy varies according to culture and environment, inadequate education, learning difficulties, and increasing cognitive decline with age are among the reasons for inadequate health literacy. This situation negatively affects the participation of individuals in disease prevention activities. Many studies show a positive relationship between low health literacy, limited cancer knowledge, and low cancer screening rates [5, 6].

However, since the rapid spread of the COVID-19 pandemic in the last two years has negatively affected the health system, services that are thought to be non-urgent have been reduced or stopped to reduce the risk of infection and the burden on health services. In addition, individuals also postponed going to health institutions due to fear of infection [7]. Therefore, one of the health services most severely affected by COVID-19 has been cancer screening programs. Decreases in cancer screening, in particular, have raised concerns, as routine screening of asymptomatic individuals reduces morbidity and mortality associated with breast, cervical, colorectal, and lung cancers [8, 9].

This study aimed to determine the cancer screening behaviors of women over 30 during the COVID-19 pandemic and to evaluate whether the screenings changed according to the sociodemographic characteristics and health literacy levels. Specifically, we sought answers to the following questions:

What is the participation rate of women in cancer screening tests during the COVID-19 pandemic period?
What are the screening tests that women attend the most and what are the associated features?
What is the health literacy level of women?
What are the defining characteristics associated with women's health literacy level?
What are the characteristics associated with women's health literacy levels and participation in cancer screening tests?

Study design and participants

The cross-sectional design study was conducted with women aged 30 and over in Edirne in northwest Turkey between July and September 2021. Edirne province is close to Greece and Bulgaria and is an urban region. The study's sample size was created on a computer-based universe. In this method, assuming that the knowledge of individuals about cancer screening tests is 50%, it was calculated as 285 with 95% power to represent the universe in the 95% confidence interval determined with a 5% margin of error. Three hundred and one women without mental disability, able to speak Turkish, residing in the city center of Edirne, aged 30 and over, who volunteered to participate and completed the online questionnaire were included in the study sample created by the snowball sample selection method.

Data Collection Tools

Personal Information Form: The form, created by the researchers through the relevant literature, consists of two parts. In the first part, health and sociodemographic characteristics (age, marital status, education level, economic level, social security, employment status, chronic illness, physical exercise), in the second part; cancer history in first-degree family members, breast self-examination, breast examination by the physician, mammography, pap smear, colonoscopy, fecal occult blood test (FBOT), screening test during the pandemic.

Turkey Health Literacy Scale (THL-32):Based on the conceptual framework developed by the European Health Literacy Research Consortium, Turkey Health Literacy Scale started being applied by the Ministry of Health in 2016 by conducting reliability and validity studies. It was developed as a 4-point Likert scale consisting of 32 items. It consists of two dimensions (treatment and service and prevention/health promotion) and four processes (accessing health-related information, understanding health-related information, evaluating health-related information, and using/applying health-related information). Each item on the scale is evaluated by scoring between 0 and 4 (1 = very difficult, 2 = difficult, 3 = easy, 4 = very easy, 0 = no idea). The total score is between 0-128. To simplify the calculation, the total score obtained from the THL-32 scale was standardized using the formula "Index=(mean-1)x(50/3)", with a score between 0–50. After the calculation, health literacy is defined as "inadequate problematic-limited health literacy (0–33 points)" and "adequate and excellent health literacy (> 33–50 points)" in order to determine sensitive groups [10]. The overall internal consistency coefficient of the THLS scale for the sample group of this study was found to be 0.79.

Data Collection Procedure

Study data were collected through an online survey. The survey showed that the COVID-19 control measures were implemented in Turkey on the 16th. Women living in the city center of Edirne were invited to participate in the study through social networks such as Facebook, Twitter, Instagram, and Whatsapp groups. In addition, the contacted women were asked to convey the questionnaire to the women around them who met the inclusion criteria. Data were collected online by sending an online survey link to individuals who met the inclusion criteria and agreed to participate in the study. The survey took a maximum of 20 minutes to complete.

Data analysis

SPSS 23.0 (Statistical Packages for Social Sciences) program was used for the statistical analysis of the study. While descriptive statistics for continuous variables were expressed as mean, standard deviation, minimum, and maximum values, categorical variables were expressed as numbers and percentages. Mann Whitney U test was used to compare continuous numerical variables for significance statistics. The Chi-square test was used to determine the relationships between categorical variables. The statistical significance level was taken as 5% in the calculations. The results were evaluated at a 95% confidence interval and p < 0.05 significance level.

The findings regarding the sociodemographic, health, and cancer screening tests and behavioral characteristics of 301 participants are presented in Table 1. The mean age was 43.66 ± 9.02; 65.1% (n: 196) of the participants were between the ages of 30–49, 85% (n:256) were married, 52.8% (n:159) were at university and higher education level, 58.1% (n:175) stated their economic status as equivalent to income and expenses, 89.4% (n:269) had social security, 51.2% (n:154) did not work in the current situation, 65.1% (n:196) did not have any chronic disease diagnosis, 82.4% (n:248) did not exercise regularly or rarely / occasionally, and 54.5% (n:164) did not have a history of cancer in their first-degree family members (Table 1).

Table 1

Socio-demographic, health and cancer screening tests behavioral characteristics of women (n = 301)
Variables	% (n)
Age group (year)
30–49	65.1 (196)
50–69	34.9 (105)
Marital status
Married	85.0 (256)
Single	15.0 (45)
Education level
High school and below	47.2 (142)
University and above	52.8 (159)
Economic level
Income less than expenses	20.3 (61)
Income equals expense	58.1 (175)
Income more than expenses	21.6 (65)
Social security
Yes	89.4 (269)
No	10.6 (32)
Work status
Working	48.8 (147)
Not working	51.2 (154)
Chronic diseases
Yes	34.9 (105)
No	65.1 (196)
Regular physical activity
Sometimes-never	82.4 (248)
Always	17.6 (53)
Family history of cancer
Yes	45.5 (137)
No	54.5 (164)
THL-32
Inadequate/problematic-limiteda	80.7 (243)
Adequate/excellent	19.3 (58)
BSE
Never	24.6 (74)
Regularly	67.8 (204)
Not regularly	7.6 (23)
CBE
No-never	67.8 (204)
Regularly	32.2 (97)
Mammography
Yes	13.6 (41)
No-never	86.4 (260)
Papsmear
Yes	21.9 (66)
No	78.1 (235)
Colonoscopy
1 once and regularly	10.0 (30)
Never and never heard	90.0 (271)
Fecal occult blood test
I've never heard of it	80.1 (241)
Regularly	19.9 (60)
Screening test during the pandemic period
Never	74.8 (225)
I took at least 1 test	25.2 (76)
THL-32: Turkey Health Literacy Scale BSE: Breast self-examination CBE: Clinical breast examination

67.8% (n:204) of the participants in the study stated that they performed breast self-examination even if they were not regular, 67.8% (n:204) stated that they never had breast examinations by a physician, 86.4% (n:260) stated that they never had mammography, 78.1% (n:235) stated that they did not have regular pap smear tests, 90.0% (n:271) stated that they never had a colonoscopy, and 80.1% (n:241) stated that they did not have FBOT. Moreover, 74.8% (n:225) did not have a screening test during the pandemic (Table 1).

According to the THL-32, 80.7% (n:243) of the participants are insufficient problematic - limited health literacy (Table 1).

When the socio-demographic and health characteristics of the participants and the distribution of the behavioral characteristics of cancer screening tests, and the differences between the groups are evaluated, those who perform breast cancer screening self-test for breast cancer reveal a significant difference between those who exercise regularly (χ²:6.455; p:0.040) and those who score sufficient and excellent health literacy level from the Turkey Health Literacy Scale (χ²:10.638; p:0.005). It was found that those who underwent breast examination tests by a physician showed a significant difference in favor of the 50–69 age group (χ²:22.09; p:0.000), those who did regular physical exercise (χ²:3.911; p:0.048), and those who had a history of cancer in first-degree family members (χ²:5.952; p:0.015). There was a significant difference in favor of those who underwent mammography screening in the 50–69 age group (χ²:48.23; p:0.000), those with high school education level and below (χ²:8.493; p:0.004), those with social security (χ²:5.646; p:0.017), those who did not work in any job (χ²:7.190; p:0.007), and those who did regular physical exercise (χ²:6.012; p:0.014) (Table 2).

Table 2

Comparison of socio-demographic and health characteristics of women and behavioral characteristics of cancer screening tests (n = 301)
Variables	Breast cancer screenings							Cervical cancer screenings		Colorectal cancer screenings				Screening test during the pandemic period
	BSE			CBE		Mammography		Papsmear		FBOT		Colonoscopy		Screening test during the pandemic period
	Never % (n)	Not regularly % (n)	Regularly % (n)	No-never % (n)	Regularly % (n)	Yes % (n)	No % (n)	Yes % (n)	No % (n)	Never % (n)	1 once and regularly % (n)	1 once regularly % (n)	Never % (n)	Never % (n)	1 once % (n)
Age group (year)
30–49	27.6 (54)	66.8 (131)	5.6 (11)	77.0 (151)	23.0 (45)	3.6 (7)	96.4 (189)	17.3 (34)	82.7 (162)	85.2 (167)	14.8 (29)	5.6 (11)	94.4 (185	78.1 (153)	21.9 (43)
50–69	19.0 (20)	69.5 (73)	11.4 (12)	50.5 (53)	49.5 (52)	32.4 (34)	67.6 (71)	30.5 (32)	69.5 (73)	70.5 (74)	29.5 (31)	18.1 (19)	81.9 (86)	68.6 (72)	31.4 (33)
test, p	χ²: 5.11; p: 0,078			χ²: 22.09; p: 0.000		χ²: 48.23; p: 0.000		χ²: 6.88; p: 0.009		χ²: 9.29; p:0.002		χ²: 11.87; p: 0.001		χ²: 3.262; p:0.071
Marital status
Married	23.4 (60)	68.4 (175)	8.2 (21)	66.4 (170)	33.6 (86)	13.3 (34)	86.7 (222)	23.4 (60)	76.6 (196)	82.0 (210)	18.0 (46)	11.7 (30)	88.3 (226)	73.4 (188)	26.6 (68)
Single	31.1 (14)	64.4 (29	4.4 (2)	75.6 (34)	24.4 (11)	15.6 (7)	84.4 (38)	13.3 (6)	86.7 (39)	68.9 (31)	31.1 (14)	-	100 (45)	82.2 (37)	17.8 (8)
test, p	χ²: 1.71; p:0.425			χ²: 1.467; p:0.226		χ²: 0.168; p:0.682		χ²: 2.282;p:0.286		χ²: 4.142; p:0.052		χ²: 5.875; p:0.016		χ²: 1.565; p:0.211
Education level
High school and below	23.9 (34)	66.9 (95)	9.2 (13)	62.7 (89)	37.3 (53)	19.7 (28)	80.3 (114)	18.3 (26)	81.7 (116)	81.7 (116)	18.3 (26)	12.7 (18)	87.3 (124)	76.8 (109)	23.2 (33)
University and above	25.2 (40)	68.6 (109)	6.3 (10)	72.3 (115)	27.7 (44)	8.2 (13)	91.8 (146)	25.2 (40)	74.8 (119)	78.6 (125)	21.4 (34)	7.5 (12)	92.5 (147)	73.0 (116)	27.0 (43)
test, p	χ²: 0.881; p: .644			x²: 3.199; p:0.074		χ²: 8.493; p: 0.004		χ²: 2.054; p: 0.152		χ²: 0.444; p:0.505		χ²: 2.199; p:0.138		χ²: 0.575; p:0.448
Economic level
Income less than expenses	26.2 (16)	63.9 (39)	9.8 (6)	68.9 (42)	31.1 (19)	16.4 (10)	83.6 (51)	16.4 (10)	83.6 (51)	78.7 (48)	21.3 (13)	9.8 (6)	90.2 (55)	77.0 (47)	23.0 (14)
Income equals expense	25.1 (44)	70.3 (123)	4.6 (8)	68.6 (120)	31.4 (55)	11.4 (20)	88.6 (155)	18.3 (32)	81.7 (143)	80.0 (140)	20.0 (35)	11.4 (20)	88.6 (155)	76.0 (133)	24.0 (42)
Income more than expenses	21.5 (14)	64.6 (42)	13.8 (9)	64.6 (42)	35.4 (23)	16.9 (11)	83.1 (54)	36.9 (24)	63.1 (41)	81.5 (53)	18.5 (12)	6.2 (4)	93.8 (61)	69.2 (45)	30.8 (20)
test, p	χ²: 6.544; p: 0.162			χ²: 0.380; p:0.827		χ²: 1.716; p: 0.424		χ²: 10.985; p: 0.004		χ²: 0.161; p: 0.923		χ²: 1.471; p: 0.479		χ²: 1.365; p: 0.505
Social security
Yes	25.3 (68)	67.3 (181)	7.4 (20)	66.5 (179)	33.5 (90)	15.2 (41)	84.8 (228)	23.8 (64)	76.2 (205)	79.6 (214)	20.4 (55)	10.4 (28)	89.6 (241)	74.3 (200)	25.7 (69)
No	18.8 (6)	71.9 (23)	9.4 (3)	78.1 (25)	21.9 (7)	-	100 (32)	6.3 (2)	93.8 (30)	84.4 (27)	15.6 (5)	6.3 (2)	93.8 (30)	78.1 (25)	21.9 (7)
test, p	χ²: 0.726; p: 0,696			χ²: 1.757; p: 0.185		χ²: 5.646; p: 0.017		χ²: 5.141; p: 0.023		χ²: 0.416; p: 0.519		χ²: 0.551; p:0.458		χ²: 0.216; p:0.642
Working status
Working	23.4 (36)	69.5 (107)	7.1 (11)	68.8 (106)	31.2 (48)	8.4 (13)	91.6 (141)	28.6 (44)	71.4 (110)	78.6 (121)	21.4 (33)	7.8 (12)	92.2 8142)	72.1 (111)	27.9 (43)
Not working	25.9 (38)	66.0 (97)	8.2 (12)	66.7 (98)	33.3 (49)	19.0 (28)	81 (119)	15.0 (22)	85.0 (125)	81.6 (120)	18.4(27)	12.2 (18)	87.8 (129)	77.6 (114)	22.4 (33)
test, p	χ²: 0.425; p:0.808			χ²: 0.161; p:0.688		x²:7.190; p:0.007		x²:8.132; p:0.004		χ²: 0.442; p:0.506		χ²: 1.662; p:0.197		χ²: 1.194; p:0.275
Chronic diseases
Yes	20.8 (22)	73.6 (78)	5.7 (6)	66.0 (70)	34.0 (36)	17.0 (18)	83.0 (88)	29.2 (31)	70.8 (75)	79.2 (84)	20.8 (22)	12.3 (13)	87.7 (93)	68.9 (73)	31.1 (33)
No	26.7 (52)	64.6 (126)	8.7 (17)	68.7 (134)	31.3 (61)	11.8 (23)	88.2 (172)	17.9 (35)	82.1 (160)	80.5 (157)	19.5 (38)	8.7 (17)	91.3 (178)	77.9 (152)	22.1 (43)
test, p	χ²: 2.632; p: 0.268			χ²: 0.226; p: 0.635		x²: 1.570; p: 0.210		x²: 5.119; p:0.024		χ²: 0.069; p: 0.793		χ²: 0.962; p: 0.327		χ²: 3.00; p:0.083
Regular physical activity
Sometimes-never	29.5 (44)	65.8 (98)	4.7 (7)	73.2(109)	26.8 (40)	8.7 (13)	91.3 (136)	17.4 (26)	82.6 (123)	86.6 (129)	13.4 (20)	7.4 (11)	92.6 (138)	78.5 (117)	21.5 (32)
Always	19.7 (30)	69.7 (106)	10.5 (16)	62.5 (95)	37.5 (57)	18.4 (28)	81.6 (124)	26.3 (40)	73.7 (112)	73.7 (112)	26.3 (40)	12.5 (19)	87.5(133)	71.1 (108)	28.9 (44)
test, p	χ²: 6.455; p: 0.040			χ²: 3.911; p: 0.048		χ²: 6.012; p: 0.014		χ²: 3.455; p: 0.063		χ²: 7.837; p: 0.005		χ²: 2.196; p: 0.138		χ²: 2.225; p: 0.136
Family history of cancer
Yes	24.8 (34)	65.0 (89)	10.2 (14)	60.6 (83)	39.4 (54)	17.5 (24)	82.5 (113)	27.0 (37)	73.0 (100)	74.5 (102)	25.5 (35)	8.8 (12)	91.2 (125)	69.3 (95)	30.7 (42)
No	24.4 (40)	70.1 (115)	5.5 (9)	73.8 (121)	26.2 (43)	10.4 (17)	89.6 (147)	17.7 (29 )	82.3 (135)	84.8 (139)	15.2 (25)	11.0 (18)	89.0 (146)	79.3 (130)	20.7 (34)
test, p	χ²: 2.485; p: 0.289			χ²: 5.952; p: 0.015		χ²: 3.245; p: 0.072		χ²: 3.791; p: 0.052		χ²: 4.965; p: 0.026		χ²: 0.409; p: 0.523		χ²: 3.896; p: 0.038
THL-32
Inadequate/problematic-limiteda	27.6 (67)	66.7 (162)	5.8 (14)	68.7 (167)	31.3 (76)	12.3 (30)	87.7 (213)	20.2 (49)	79.8 (194)	80.7 (196)	19.3 (47)	9.9 (24)	90.1 (219)	74.5 (181)	25.5 (62)
Adequate/excellent	12.1 (7)	72.4 (42)	15.5 (9)	63.8 (37)	36.2 (21)	19.0 (11)	81.0 (47)	29.3 (17)	70.7 (41)	77.6 (45)	22.4 (13)	10.3 (6)	89.7 (52)	75.9 (44)	24.1 (14)
test, p	χ²: 10.638; p: 0.005			χ²: 0.521; p: 0.470		x²: 1.744; p: 0.187		x²: 2.288; p: 0.130		χ²: 0.277; p: 0.599		χ²: 0.011; p: 0.915		χ²: 0.047; p: 0.828
THL-32: Turkey Health Literacy Scale BSE: Breast self-examination CBE: Clinical breast examination

A significant difference was found in favor of those who performed cervical cancer screening in the 50–69 age group (χ²:6.88; p:0.009), whose economic status was an excess income (χ²:10.985;p:0.004), those with health insurance (χ²:5.141; p:0.023), those who worked in a job (χ²:8.132; p:0.004), and those with chronic diseases (χ²:5.119; p:0.024).

Of those who had FBOT for colorectal cancer screening, those in the 50–69 age group (χ²:9.29; p:0.002), who did regular physical exercise (χ²:7.837; p: 0.005) and who had a history of cancer in first-degree family members (χ²:4.965; p: 0.026) were statistically significant. In addition, those 50–69 age group (χ²:11.87; p: 0.001), had a colonoscopy test, and were married (χ²:5.875; p:0.016) were statistically significantly different. During the pandemic, the behavior of having a screening test was statistically significant in those with a history of cancer in first-degree family members (χ²:3.896; p:0.048). It is shown in Table 2.Discussion

It is known that the Covid-19 pandemic has deeply affected health services. Many medical procedures and elective and non-urgent planned surgeries were canceled or rescheduled [11]. In many countries, screening, diagnosis, and treatment services decreased by more than 90%[8], and community-based cancer screening programs were suspended [11]. When the screening data for the pandemics were compared with the screening data for 2019, it was observed that the cancer screening rates decreased significantly during the lockdown [8, 9]. In a study conducted by the International Agency for Cancer Research (IARC) to investigate the effect of COVID-19, it was reported that screening decreased by 61.1%, diagnosis by 44.4%, and treatment by 22.2% in low- and middle-income countries compared to the pre-pandemic days [12]. In a study in which approximately 11 million individuals in the United States participated, it was shown that participation in breast cancer screenings decreased by 96% [9], and in a different study, by 87% [13]. In another study, cervical cancer screenings decreased very severely in the 21–29 age group to 78%, in women between the ages of 30–65 to 82% 91]. and in another study to 84% [13]. According to the Turkish Ministry of Health data, nine million people were screened for cancer in 2019, which decreased to three million in 2020 [14]. This study determined that 3 out of every four women had no screening tests during the pandemic. Although the results differ from country to country, it can be said that the COVID-19 pandemic significantly reduced cancer screening tests in general.

The most common screening test performed by the participants was breast examination (32.2%) under the control of a physician, followed by a pap smear test (21.9%) and FBOT (19.9%). The study found that the rates of women's regular breast self-examination (7.6%) and mammography (13.6%) were relatively low. In the literature, it has been reported that the proportions of women who perform breast self-examination (BSE), have clinical breast examination (CBE), and have mammography in developing countries vary between 17% and 50%, between 20% and 47%, and between 20% and 55%, respectively [15–20]. In studies conducted at the local level before the pandemic in Turkey, it has been reported that the proportions of women who performed BSE, had CBE, and had mammography varied between 13% and 49%, 15% and 36%, and 20% and 38%, respectively [21–25].

In the study, it was found that in the 50–69 age group, women who graduated from university, did the physical activity, and had a family history of cancer had more mammography. Studies have reported that having a family history of cancer increases awareness, and women with high health perceptions are more likely to participate in screening programs [26]. Our findings are consistent with the literature. It is expected that people who show positive health behaviors have features such as high education and physical activity.

One out of every five women undergoes regular pap smear screening in this study. Similarly, in developing countries before the pandemic, this rate was27.2% in Malaysia,²⁷ 31.3% in Turkey [28], and 32% in Iran [29]. In developed countries, 70% had pap smear tests in Finland [30], 89.1% in the USA [31], 83% in the UK [32], and 94% of women in Greece [33]. Although these studies were limited during the pandemic, they were as low as 44.1% in the USA [34] and 52.2% in Korea [35]. Until June 2020, it is reported that the 5-year screening rate average decreased below 40% [13], and approximately 46% of women between the ages of 30–49 in Germany postponed their cancer screening [36]. Although the reason for the low rate is the pandemic, it is thought that the rate of testing is low due to the lack of sufficient information about the pap smear test in local studies.

However, the study determined that women with low income, not working and without social security had less pap smear screening. These factors, defined as social determinants of health, are the primary determinants affecting the protection and development of health. These situations are expected to be solved long-term by expanding the country's health systems and education opportunities. Indeed, in 2015, the United Nations set several sustainable development goals that should be achieved by 2030 as a global initiative. Goal 3.4 aims to reduce premature deaths from non-communicable diseases, including cancer, by one-third. Likewise, the 2020 World Health Assembly Resolution set ambitious targets for eliminating cervical cancer as a public health problem [37]. For this purpose, all women were contacted and included in the screening programs, and HPV vaccination applications were required [38]. As a result of these global goals, it is emphasized that vaccination and comprehensive screening with HPV tests have the potential to prevent 12.5–13.4 million cervical cancer cases in the next half century [39]. Precautions should be taken urgently for the scans which decreased during the pandemic to increase participation in the scans.

In the study, it was found that approximately one in five individuals participated in colorectal cancer screening. In Turkiye's Colorectal Cancers National Control Program, the coverage rate of CRC scans has been reported to be 20–30% [4]. In a multicenter study, the average participation rate in colorectal cancers scans in the Asia-Pacific region was 27%, with the highest participation rate in the Philippines and the lowest in India [40]. Similarly, in some studies conducted with adults, the frequency of participation in the FBOT was twice as high as in colonoscopy scans [41, 42]. Various reasons reduce participation in cancer screenings, and it is vital to determine the relevant factors to solve these reasons. The study determined that approximately 80% of the participants did not hear the fecal occult blood testing and did not get it done. However, even though the awareness of the FBOT is low, it is a pleasing finding that people who know have had this screening. In studies, the rate of not knowing the FBOT is 19.6% -82.7% [43–45]. Knowing and having colorectal screening tests are significantly higher in the 50–69 age group and those with a family history of cancer. Because of the progressed age, being a cancer patient or having cancer within family members increase the perception of cancer risk, and health-protective practices increase [44]. The higher screening awareness in the group that exercises regularly coincides with and supports this result.

According to the THL-32 survey score, 80.7% of the participants in the study were at inadequate and problematic health literacy levels. Considering the findings of the THL a study conducted by the Ministry of Health in Turkey, this rate was reported to be 68.9% and 75.7% in the study by Yakar et al [45]. Contrary to these results, studies are reporting that it has a better health literacy level [46]. However, the health literacy levels of the participants in the current study show that our health literacy levels are low compared to the US and European data. The European Health Literacy study covering eight European Union member countries determined 12.4% insufficient, 35.2% problematic, 36% adequate, and 16.5% excellent health literacy. While low health literacy was reported in 29% of developed countries such as the Netherlands, low health literacy was found in 62% of developing countries such as Bulgaria [47]. It is seen that Turkiye's results are insufficient compared to the countries within the scope of European health literacy. In this context, according to the general THL scores, it is unlikely that the participants' participation in cancer screening will be high due to their low health literacy and excellent ones. For example, in various studies, it has been reported that those with poor health literacy are less likely to comply with colorectal screening and that there is an obstacle to participating in screening [48].

Similarly, in this study, the rates of BSE were significantly different in the group with high levels. In other studies, participation in BSE and screening tests is higher in those with high health literacy levels [15, 18, 49]. If health literacy is at an adequate-perfect level, individuals may have perceived messages about healthy behaviors more efficiently and therefore adopt them more quickly, and as a result, BSE may be higher in individuals.

In this study, the evaluation of screening behaviors of women aged 30 and over for early cancer diagnosis during the pandemic is one of the study's strengths. However, the study is cross-sectional and based on self-report; therefore, the causality relationship cannot be determined among the study's limitations.

Women over the age of 30 have low levels of participation in cancer screening tests and health literacy. The critical reason is that cancer screenings are negatively affected due to the global response to the COVID pandemic. For this purpose, more extensive sample studies, focus groups, or in-depth interviews should be conducted to determine the factors affecting participation in cancer screening tests.

The literature states that the most crucial obstacle to behavior development is a lack of awareness and/or negative perception. This process can be changed by initiatives to increase access to education, counseling, and health services [50]. Primary health care institutions should organize training and counseling programs to improve health literacy and understand the benefits of screening behaviors. Moreover, in the context of cancer screening tests, it is necessary to increase the capacities that can be applied at the health system level to improve access and disseminate information to increase community participation and mobilize remarkable innovations and adaptations.

We also suggest that screening behaviors should be evaluated according to the records of health institutions, not according to self-reports.

Ethics approval and consent to participate The study design was approved by the Ministry of Health of the Republic of Turkey and the Non-Interventional Clinical Research Ethics Committee (TUTF-2021/281) of Trakya University Faculty of Medicine. An informed consent form has been added to the first page of the online data collection form. After the participants read the consent form and voluntarily agreed to participate in the study, they answered the data collection form.

Consent for publication 30 years and up women participants provided online informed consent to take part in the study, including consent for publication of research studies.

Availability of data and material The study data is shared if the legal procedure is provided. There are some restrictions and researchers can access the data by applying to the university. Therefore the data used for this study cannot be made publicly available.

Competing interests No potential conflict of interest was reported by the author(s).

Funding No financial support was received and the expenses were covered by the researchers.

Authors'contributions Study conception and design: UC. Acquisition, analysis, and interpretation of data: All authors. Critical revision for important intellectual content: All authors. Statistical analysis: AYI. Obtained funding: UC and AYI. Administrative, technical, or material support: UC and AYI. Study supervision: UC. All authors approved the final version of the manuscript before submission.

Acknowledgments All authors thank the women who supported the study.

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No competing interests reported.

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Cancer Screening Behaviors and Health Literacy Levels of Women aged 30 and over

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