Women’s attitudes towards healthy life awareness and breast cancer screening during the coronavirus disease 2019 pandemic: a cross-sectional descriptive study

Abstract

Background 

In the COVID-19 pandemic, fear of coronavirus infection has caused individuals to hesitate to access medical services and postpone their participation in diagnostic and screening programs. With this research, it was aimed to examine the relationship between women’s wellness awareness and attitudes towards breast cancer screening during the COVID-19 pandemic.

Methods 

The descriptive cross-sectional type research was conducted between 30 January 2021 and 30 July 2021. The sample of the study consisted of 396 women between the ages of 40 and 69 who were in the breast cancer screening population under national cancer screening standards and met the criteria for inclusion. The data of the study were collected using a web-based and self-reported questionnaire, Personal Information Form, Healthy Life Awareness Scale and Cancer Screening Attitude Scale.

Results 

It was determined that more than half of women postponed breast cancer screening during the COVID-19 pandemic, and the reasons for the postponement were often fear of contamination. It was determined that there was a relationship between the participants’ awareness of healthy living and their attitudes towards cancer screening (P < 0.05).

Conclusion 

It was found that approximately two out of every three women in the screening population during the pandemic did not have screening or postponed it due to fear of contamination. It was determined that women who had awareness of healthy living and had breast cancer screening before the pandemic had a positive attitude towards cancer screening during the COVID-19 pandemic period.

Introduction

The coronavirus disease 2019 (COVID-19) remains a public health emergency of the 21st century, with approximately five million (4 746 620) deaths and 230 million (231 703 120) cases worldwide since the pandemic was declared (https://covid19.who.int/). At the global level, restrictions have been imposed on nonurgent healthcare services such as cancer screening to reduce the risk of transmission of COVID-19 infection and the burden on healthcare services (^{Basu et al., 2021; Gorin et al., 2021; Maio et al., 2021}). In this process, the American Cancer Society has published recommendations for individuals not to go to health institutions for periodic cancer screening and to postpone it to a later date (^{Gorin et al., 2021}). At the same time, fear of transmission of COVID-19 has caused individuals to hesitate in accessing medical services and delay their participation in diagnosis and screening programs (^{Basu et al., 2021; Gathani et al., 2021}). In this context, it is estimated that the restrictions and disruptions caused by the COVID-19 pandemic may increase the incidence and mortality rates of many chronic diseases, including cancer in the future (^{Basu et al., 2021}).

Breast cancer is the most common cancer in women in the world as well as Turkey (Globocan Observatory, 2020). In Europe and the USA, a reduction in cancer-related deaths has been achieved with national screening programs (^{Sharma et al. 2020}). Many international breast screening societies have suggested that breast cancer screenings may be delayed ‘until restrictions are lifted’ for low priority situations during the pandemic (Durur Subasi, 2020; ^{Pediconi et al., 2020; Seely et al. 2020; Freer, 2021}). However, the unpredictable spread of COVID-19 infection and the prolongation of more than a year have interrupted breast cancer screening activities, resulting in barriers to access to early detection (^{Ginsburg et al., 2020}). It has been predicted that an estimated 3-month screening delay can lead to 8125 breast cancer cases undiagnosed in Italy (^{Vanni et al., 2020}). Considering the unpredictable consequences of the pandemic, it is estimated that as a result of a 6-month delay, 50% of the 11 180 breast cancer cases (5590 or higher) will be diagnosed with advanced cancer in Italy (^{Vanni et al., 2020}). As a result of this delayed diagnosis, it is predicted that an increase in the incidence of breast cancer and an increase in the cost of treatment and health care will increase the burden of health systems in the future (^{Maio et al., 2021}).

The conscious awareness of individuals in the healthy population to acquire healthy lifestyle behaviors is defined as healthy living awareness (^{Özer and Yilmaz, 2020}). Increasing awareness of healthy living in women will increase the early detection of breast cancer and increase survival rates by ensuring their regular participation in routine screening programs (^{Duman et al., 2015; Enjezab, 2016; Che Mohamed et al., 2019}). Within the scope of national cancer screening standards, it is recommended to perform breast self-examination once a month, a clinical breast examination once a year, and a mammography every 2 years for the 40–69 age group. Since 2006, community-based screenings are carried out by Cancer Early Diagnosis, Screening, and Education Centers. Opportunistic screenings are performed on women who apply to hospitals. Women are invited to breast cancer screenings by family health centers via letter or telephone, and necessary examinations and tests are carried out. According to the 2016 data of the National Cancer Control Plan, 30–35% of the target female population was screened within the scope of the breast cancer screening program. Within the scope of population-based screenings, it was reported that 2 million 500 thousand women aged 40–69 years were screened for breast cancer in 2019 and 700 thousand women in the first 6 months of 2020 (^{Keskinkiliç et al., 2016; Gök et al., 2019; Babaoğlu et al., 2021; Bulut et al., 2021}; https://hsgm.saglik.gov.tr, 2021). As cancer screening was postponed or canceled worldwide due to the pandemic (^{Basu et al., 2021; Gathani et al., 2021; Gorin et al., 2021}), also breast cancer screening was postponed or canceled during the pandemics in Turkey. Currently, the real extent of the postponement or cancelation of breast cancer screening, which caused this decrease during the pandemic period in Turkey, has not been clarified. It is the professional responsibility of nurses to encourage and support the participation of women in screening programs in the prevention of breast cancer. Nurses, who have an important role in the protection and development of public health, can raise awareness of healthy life by creating awareness of breast cancer in women (^{Kabacaoğlu and Karaca, 2020}).

In the literature, there are limited number of studies examining the breast cancer screening participation rates, activities (^{Ginsburg et al., 2020; Gathani et al., 2021; Maio et al., 2021; Gorin et al., 2021}), and screening status of women during the pandemic process (^{Toyoda et al., 2021}). However, no study has been found that reveals the reasons why women do not have screening during the pandemic process, and their healthy life awareness and screening attitudes in Turkey.

Material and methods

Study design and participants

This research was conducted in a descriptive and cross-sectional type to examine the relationship between women’s awareness of healthy life and their attitudes towards breast cancer screening during the COVID-19 pandemic process in Turkey.

The population of the study consisted of women aged 40–69 years who did not have a history of breast cancer in the community, were included in the breast cancer screening population within the scope of national cancer screening standards, were residing in Turkey, and met the inclusion criteria. The sample of the study was determined according to the sampling method of unknown population. Taking the prevalence of unknown as 50%, the smallest sample size determined for the unknown population size at 5% deviation and 95% confidence interval was calculated as 384 (n = [(1.96)² × (0.5) × (0.5)]/(0.05)² (^{Hulley et al., 2013}). Since the research was not conducted within the framework of a screening program, no participant list was created. Between the dates of the study, an online questionnaire was sent to a total of 428 women, whom the researchers reached through social media groups. In the sample of the study, 396 women who answered all questions were included.

The inclusion criteria were as follows: (a) women aged 40–69, (b) volunteer to participate in the study, (c) literate, and (d) able to use social media, smart phone, or computer.

The exclusion criteria were as follows: (a) have a history of breast cancer, (b) have any communication problems, and (c) refuse to participate in the study.

Measures

The data of the study were collected between 30 January 2021 and 30 July 2021. The data were obtained by using the web-based and self-reported questionnaires method by sharing the online questionnaire form link created by the researchers using the URL address ‘surveey.com’ and sharing them with women aged 40–69 in the society via their social media accounts.

To collect data, a personal information form was used together with Healthy Life Awareness Scale (HLAS) and Attitude Scale for Cancer Screening (ASCS).

Personal information form

This form, which was developed by researchers by examining the relevant literature, consists of a total of 16 questions and two chapters. In the first part, there are nine questions that include the sociodemographic characteristics of women (age, educational status, income level, place of residence, etc.). In the second part, there are seven questions about breast cancer/screening of women and their screening practices during the pandemic (previous screening, family history, etc.) (^{Enjezab, 2016; Che Mohamed et al., 2019; Gök et al., 2019}).

Healthy life awareness scales

The scale, which was developed by Yilmaz and Ozer (2020) to measure the healthy life awareness levels of individuals, consists of 15 items and four subdimensions (change, socialization, responsibility, and nutrition). The change in subdimension (items 1–5) includes the individual’s awareness of the changes in their body; the socialization subdimension (items 6–9) includes the individual’s attention to health issues in their daily life; the responsibility subdimension (items 10–12) includes the individual’s awareness of the effects of their negative health behaviors, feelings, and emotions on their health; and the nutrition subdimension (items 13–15) includes the individual’s awareness of the effects of diet on their health. There is no reverse item among the scale items. The scale constitutes the 5-point Likert type and consists of the following criteria: ‘5: I totally agree, 4: I somewhat agree, 3: I neither agree nor disagree, 2: I somewhat disagree, and 1: I strongly disagree’. Given that change (5–25 points), socialization (4–20 points), responsibility (3–15 points), and nutrition (3–15 points), the lowest score that can be obtained from the scale is 15, whereas the highest score is 75. Getting a high score from the scale is considered as a high level of healthy living awareness. While the Cronbach-alpha value was 0.81 in the study by Ozer and Yilmaz (^{Özer and Yilmaz, 2020}), it was found to be 0.95 in this study.

An attitude scale for cancer screening

The scale was developed by Öztürk et al. (2020) in pursuit of determining the attitude towards cancer screening in male and female adults aged 30–70 years. The scale consists of one dimension and 24 items. The scale constitutes the 5-point Likert type and consists of the following criteria: ‘5: I totally agree, 4: I somewhat agree, 3: I neither agree nor disagree, 2: I somewhat disagree, and 1: I strongly disagree’. The lowest score that can be obtained from the scale is 24, and the highest score is 120. The scale does not have a specific cutoff point. It is thought that as the scores of the participants approach 24, they have a negative attitude towards cancer screenings; and as they approach 120, they show a positive attitude towards cancer screenings. While calculating the scale scores, 13 items (Items 9, 12, 14–24) are reverse-coded. It is recommended to use the ‘6−Participant Response’ formula for reverse coding. While the Cronbach-alpha value was 0.95 in the study by Ozturk et al., (^{Yildirim Öztürk et al., 2020}), it was found to be 0.86 in this study.

Statistical analysis

Descriptive statistics were used for continuous variables (mean, SD), whereas frequency distributions were determined for categorical variables. The Shapiro–Wilk test, histogram, and normal Quantile-Quantile plot were used for tests of normality. One-way ANOVA and independent sample t-test were used to evaluate the difference between individuals’ sociodemographic characteristics, independent variables, and the ASCS mean score. Pearson correlation analysis was used to evaluate the difference between the mean score of the HLAS and all its subdimensions, the mean knowledge score for breast cancer screenings, and the ASCS. Multiple regression analysis was performed. All statistical analyses were carried out in SPSS 21 (Armonk, New York, USA), and P < 0.05 was considered to be significant.

Ethical considerations

The study was approved by the Non-Interventional Clinical Research Ethics Committee at Izmir Bakirçay University in Turkey (29.01.2021/183) and performed in accordance with the Helsinki Declaration. Participants first read the informed consent text, which explains the purpose and rationale of the study, in the link containing the questionnaire sent online. After getting information about the study, ‘Would you like to participate in the study voluntarily?’ They answered ‘Yes or No’ to the question. Volunteers from the participants filled out the questionnaire. They were informed that they could withdraw from the study at any time without stating a reason.

Results

Sociodemographic characteristics and breast cancer attitudes of the participants

It was determined that the mean age of the participants was 48.69 ± 6.75, 86.40% were married, 56.00% had a bachelor’s degree, and 56.10% did not work in any job. It was determined that more than half (69.90%) of the women participating in the study had breast cancer screening at least once in their lifetime. The participants stated the reasons for having breast cancer screening for the first time as being in the age-related risk group (38.40%), experienced symptoms (17.50%), and health personnel recommendation (12.90%). When the breast cancer screening status of the participants during the pandemic process was examined, it was found that 54.30% of them did not have screening and postponed it. They stated that the most common reasons for postponement were fear of contamination (62.30%), the thought of not increasing the burden of health personnel (19.00%), and restrictions (18.60%) (Table 1).

Table 1 - Introductory characteristics of the participants and their attitudes towards breast cancer screening (n = 396)

Characteristics	n (%)
The average age: 48.69 ± 6.75 (40.00–87.00)
Age group
40–49 years	233(58.80)
50–59 years	135(34.10)
60–69 years	28(7.10)
Marital status
Married	342 (86.40)
Single	54 (13.60)
Educational status
Primary school	32 (8.10)
Secondary education	59 (14.90)
Undergraduate	222 (56.00)
Graduate	83 (21.00)
Working status
Working	222 (56.10)
Not working	174 (43.90)
Income status
Income less than expenses	76 (19.20)
Income equal to expenses	219 (55.30)
Income more than expenses	101(25.50)
Living place
Town center	294 (74.20)
Rural	102 (25.80)
Family history of breast cancer
Yes	67 (16.90)
No	329 (83.10)
The status of having breast cancer screening before the pandemic
Yes	277 (69.90)
No	119 (30.10)
Reasons for applying for breast cancer screening for the first time
Family history of cancer	16 (4.00)
By age	152 (38.40)
Health personnel recommendation	51 (12.90)
Complaints experienced	69 (17.50)
Family recommendation	18 (4.60)
The status of having breast cancer screening during the pandemic process
Yes	215 (54.30)
No	181 (45.70)
Reason for affecting breast cancer screening during the pandemic process(n = 215)
Fear of contagious COVID	134 (62.30)
The idea of not increasing the workload of health workers	41 (19.00)
Lockdown	40 (18.60)

Participants’ healthy life awareness scale and attitude scale towards cancer screening mean scores and their relation

It was determined that the mean HLAS score of the women in the 60–69 age group in the study group was lower than the other groups (P < 0.05), whereas the mean HLAS score of the women with a postgraduate education level and whose income was higher than expenditures was found to be higher (P < 0.05). (Table 2).

Table 2 - Attitude scale towards cancer screening scale and healthy living awareness scale score distributions on participants’ introductory characteristics and attitudes towards breast cancer screening (n = 396)

Variables	Healthy life awareness scales			An attitude scale for cancer screening
	X̄ ± SD	Test	P	X̄ ± SD	Test	P
Age group
40–49 years	61.41 ± 9.70	3.575	0.029*	98.81 ± 14.28	3.265	0.039*
50–59 years	60.38 ± 9.98			102.05 ± 12.89
60–69 years	55.96 ± 12.60			96.19 ± 14.92
Marital status
Married	60.21 ± 10.22	a-2.491	0.013*	99.95 ± 13.54	a0.721	0.471
Single	63.87 ± 8.58			98.48 ± 16.39
Educational status
Primary school	57.46 ± 12.61	4.013	0.008*	98.53 ± 14.13	1.207	0.307
Secondary education	57.62 ± 10.90			97.03 ± 14.12
Undergraduate	61.41 ± 10.15			100.73 ± 13.24
Graduate	62.22 ± 7.34			99.53 ± 15.49
Working status
Working	61.19 ± 10.22	1.065	0.288	99.46 ± 14.02	−0.468	0.640
Not working	60.10 ± 8.58			100.12 ± 13.90
Income status
Income less than expenses	59.02 ± 11.73	2.977	0.042*	99.71 ± 14.22	b0.053	0.948
Income equal to expenses	60.42 ± 9.37			99.59 ± 14.05
Income more than expenses	62.61 ± 10.02			100.13 ± 1.64
Living place
Town center	60.84 ± 9.67	0.431	0.666	99.90 ± 13.53	0.354	0.724
Rural	60.34 ± 11.21			99.33 ± 15.16
Family history of breast cancer
Yes	61.02 ± 11.	0.280	0.789	102.67 ± 13.06	−1.883	0.060
No	60.65 ± 9.72			99.6 ± 14.07
The status of having breast cancer screening before the pandemic
Yes	61.21 ± 10.60	1.503	0.134	103.06 ± 12.82	−7.716	0.000*
No	59.55 ± 8.67			92.05 ± 13.48
The status of having breast cancer screening during the pandemic process
Yes	60.93 ± 9.67	0.483	0.689	101.37 ± 13.49	−2.538	0.012*
No	60.44 ± 10.56			97.82 ± 14.28

*P < 0.05.

^at = Independent samples t-test.

^bF = One-way ANOVA.

The mean ASCS scores of women aged 60–69 years included in the study were found to be statistically significantly lower than other age groups. When the ASCS mean scores of women according to their breast cancer screening tests were examined, it was found that the ASCS score averages of the women who had regular screening before the pandemic were higher than those who did not, and the difference was statistically significant (P < 0.001). ASCS mean scores of women who had breast cancer screening tests during the pandemic process were found to be significantly higher (P < 0.05). There was no statistically significant difference between the mean HLAS scores of women who had and did not have regular screening before the pandemic (P > 0.05) (Table 2).

In the study, the participants’ ASCS score average was found to be 99.75 ± 13.95; HLAS score average was 60.71 ± 10.08. It was determined that the participants had a mean score of 21.28 ± 3.62 from the change subdimension, which is one of the HLAS subdimensions, 15.61 ± 3.56 from the socialization subdimension, 12.36 ± 2.32 from the responsibility subdimension, and 11.44 ± 2.90 from the nutrition subdimension (Table 3).

Table 3 - The participants in the study during the pandemic attitude scale towards cancer screening scale, healthy living awareness scale, and subdimensions score averages (n = 396)

Variables	X̄ ± SD	Min.–Max.
Attitude scale towards cancer screening (ASCS)	99.75 ± 13.95	41.00–120.00
Healthy Living Awareness Scale (HLAS)	60.71 ± 10.08	15.00–75.00
HLAS change subdimension	21.28 ± 3.62	5.00–25.00
HLAS socialization subdimension	15.61 ± 3.56	4.00–20.00
HLAS responsibility subdimension	12.36 ± 2.32	3.00–15.00
HLAS nutrition subdimension	11.44 ± 2.90	3.00–15.00

In the study, it was determined that there was a statistically highly significant and weak relationship between the participants’ average scores of HLAS and all its subdimensions and the ASCS score average (P < 0.05) (Table 4).

Table 4 - The relationship between the participants’ mean scores on healthy living awareness scale and its subdimensions and the attitude scale towards cancer screening scale mean score

Variables	Attitude scale towards cancer screening
	r	P
Healthy living awareness scale	0.318	<0.001
HLAS change subdimension	0.300	<0.001
HLAS socialization subdimension	0.236	<0.001
HLAS responsibility subdimension	0.249	<0.001
HLAS nutrition subdimension	0.240	<0.001

Pearson correlation test.

The result of the regression analysis is presented in Table 5. It has been determined that women with a high level of awareness of healthy living and who had breast cancer screening before the pandemic had a high attitude towards cancer screening during the pandemic period. These variables explain 21.00% of the variation in the ASCS score (Table 5).

Table 5 - Stepwise multiple regression analysis of predictors of attitude scale towards cancer screening scale

Variables	Unstandardized coefficients		Standardized coefficients	t	P
	B	SE	Beta
Constant	67.969	3.862		17.598	<0.001
Mean scores on HLAS	0.404	0.062	0.292	6.654	<0.001
The status of having breast cancer screening before the pandemic	10.340	1.362	0.340	7.597	<0.001

R = 0.465; R2 = 0.219; adjusted R² = 21.2; F = 54.186; P < 0.001. Linear regression analysis.

Discussion

The restrictions applied during the pandemic process at the global level have caused delays in the processes of going to health institutions for cancer screening, diagnosis, and treatment (^{Basu et al., 2021; Gorin et al., 2021; Maio et al., 2021}). Our research findings show that more than half (54.3%) of women aged 40–69 in the screening group in the COVID-19 pandemic did not have or postpone breast cancer screening. In Japan, it was stated that 26.3% of women aged 30–79 in the breast cancer screening group postponed or canceled breast cancer screening during the pandemic process (^{Toyoda et al., 2021}). In the study in Japan, it was observed that one out of every four women postponed the screening during the pandemic, whereas one out of every two women included in our study delayed the screening. When the breast cancer screening rates of other countries are examined during the pandemic process, it has been reported that there is an immediate decrease of 94% according to the US cancer screening model and a decrease of 28% in the UK when the first 6 months of 2019–2020 data are compared (^{Gorin et al., 2021; Gathani et al., 2021}). When comparing the screening rates for 2017–2020 in Taiwan, it was found that there was a decrease from 41 to 57% in the first trimester of the pandemic (^{Peng et al., 2020}). Although there are no national data on cancer screening during the pandemic process in Turkey, it was stated in a study that there was a 78.5% decrease in breast cancer screening rates during the pandemic (^{Esmeray et al., 2021}). It is predicted that the delay or postponement of cancer screening due to the pandemic will increase the incidence and mortality rates and increase the cancer burden in the future (^{Basu et al., 2021; Maio et al. 2021}). Today and in the future, different approaches and strategies can be developed so that the pandemic does not interrupt cancer screenings. In this context, practices such as planning individualized screening practices, prioritizing screening referrals to women with high risk of breast cancer, increasing the number of mobile mammography units for easy access to screening activities, and home testing of biomarkers that determine breast cancer early diagnosis can be recommended (^{Peng et al., 2020; Gorin et al., 2021}).

In the study, it was determined that more than half of the women (62.3%) often postponed or did not have breast cancer screening during the pandemic due to fear of contamination, the thought of not increasing the workload of healthcare professionals, and lockdowns. It is emphasized that the fear of contagion of COVID-19 affects the perceived risk level in the society and causes hesitations about having cancer screening (^{Peng et al., 2020; Basu et al., 2021; Gathani et al., 2021; Gorin et al., 2021}). Our research findings are similar to the literature. In a study that differed from our research findings, it was stated that fear of transmission of COVID-19 did not affect women’s postponement or cancelation of breast cancer screenings (^{Toyoda et al., 2021}). In order to minimize the risks perceived by the society, to provide personal protective equipment in the screening units in order to restart breast cancer screening during and after the pandemic, to arrange the waiting areas in such a way that physical distance can be maintained, and to prevent crowding, strategies such as introducing an appointment system, evaluation of individuals in terms of COVID-19 symptoms before screening, rapid testing for the detection of COVID-19, repetition of sterilization, and disinfection processes at periodic intervals can be applied. It is anticipated that the willingness to participate in screening can be increased by making the screening units safe of women who do not have screening due to fear of contamination and postpone it (Durur Subaşi 2020; ^{Peng et al., 2020; Seely et al., 2020; Freer, 2021}).

In the study, it was found that as the age of women increased, their awareness of healthy life decreased, and as their education and income level increased, their awareness of healthy life increased. According to our findings, it is thought that the perception of illness may change with increasing age, the level of awareness will increase with the increase in education level, and the higher the income level, the higher the accessibility. Studies have also reported that women’s age, education, and income level are effective in the development of women’s screening awareness (^{Duman et al., 2015; Enjezab, 2016; Gök et al., 2019}). The results of the studies in the literature support our research findings. Considering the epidemiological data of breast cancer, it is critical to raise awareness of healthy living in every age group and to develop screening behaviors, in terms of contributing to the early diagnosis of breast cancer and diagnosis at an early stage.

In the literature, it is suggested that women are more likely to have screening practices if they are aware of breast cancer early detection methods (^{Che Mohamed et al., 2019}). On the contrary, it was stated that although women think that early diagnosis is important in breast cancer and they have breast cancer awareness, their screening attitudes and behaviors are insufficient (^{Yusof et al., 2014; Che Mohamed et al., 2019; Gök et al., 2019; Şen and Kiliç Öztürk, 2020}). Our findings showed that the attitudes of women who had regular screening before the pandemic towards cancer screening were highly positive compared with those who did not, and that the attitudes of women who were screened during the pandemic were more positive than those who did not. It was determined that the positive attitudes towards cancer screening of women participating in our study affected their breast cancer screening behaviors before and during the pandemic. Studies have reported that there is no significant relationship between having a positive attitude towards screening and having breast cancer screening (^{Yusof et al., 2014; Tuzcu et al., 2018; Şen and Kiliç Öztürk, 2020}). It is important to increase awareness and to gain the behaviors to participate in screening in developing positive attitudes towards cancer screening in women. It is thought that nurses should periodically organize training programs in order to increase breast health awareness for women, and encourage and support women’s participation in screening programs in the prevention of breast cancer. It is recommended that awareness trainings for the target population be disseminated through social media, and printed, visual, and audio media (^{Kabacaoğlu and Karaca, 2020; Kulakçi and Korkmaz, 2020}). In this direction, it is an inevitable approach that policies and strategies need to be produced so that screening can be restarted during the pandemic period.

A weak correlation was found between our participants’ awareness of healthy living and their attitudes towards cancer screening. In the literature, it is emphasized that the perception of health and the development of healthy lifestyle behaviors of individuals have an effect on the behaviors of prevention from diseases (^{Che Mohamed et al., 2019; Özer and Yilmaz, 2020; Özkan, 2021}). Studies have shown that individuals with healthy lifestyle awareness and healthy lifestyle behaviors have a significantly reduced risk of chronic disease, mortality, and morbidity compared with those who do not (^{Ford et al., 2012; Özer and Yilmaz, 2020}). It has been found that awareness of healthy living develops a positive attitude towards screenings (^{Özer and Yilmaz, 2020; Şen and KiliçÖztürk, 2020}). Our study findings are similar to the literature, and women’s awareness of healthy lifestyles and their status of having breast cancer screening before the pandemic were found to be important determinants of women’s attitudes towards cancer screening.

During the COVID-19 pandemic, it was found that approximately two out of every three women in the 40–69 age range in the screening population did not have or postponed screening due to fear of contamination. In the pandemic, it was determined that there was a relationship between women’s awareness of wellness and their attitudes towards breast cancer screening. It was determined that women who had awareness of healthy living and had breast cancer screening before the pandemic had a positive attitude towards cancer screening during the pandemic period. Since the pandemic process is still ongoing, it is recommended to implement policies that provide an opportunity to develop strategies so that screenings are not interrupted in the future.

Limitations

The present study has strengths as it is the first study to show the effects of the pandemic on screening attitudes of women in the breast cancer screening population in Turkey. This study has some limitations as well as strengths. It is limited to the data of women aged 40–69 years included in the study and cannot be generalized to the entire female population between the ages of 40–69 in Turkey. Second, the data collection process could not be controlled because the data collection forms were filled as self-report in online. Finally, the data of the study could not be collected by face-to-face interview method due to the pandemic. The exclusion of women who cannot use social media, smart phones, or computers in the sample so that the data can be obtained with an online questionnaire may have led to selection bias.

Acknowledgements

The authors are grateful to the women who participated in this study.

D.Ç.: conceptualization, methodology, data collection and curation, resources, writing e original draft, supervision; A.Ç.: conceptualization, methodology, software, writing e original draft, supervision; A.Ö.: methodology, software, formal analysis; P.Z.B.: methodology, resources, writing e original draft; N.K.A.: data collection and curation, resources, writing e original draft, supervision.

Ethical statement: the study was approved by the Non-Interventional Clinical Research Ethics Committee at a university in Turkey (decision no: 2021/183).

Conflicts of interest

There are no conflicts of interest.