The authors have declared that no competing interests exist.
Breast cancer (BC) has been described as the leading cause of cancer deaths among women especially in the developing world including sub Saharan Africa (SSA). Delayed presentation and late diagnosis at health facilities are parts of the contributing factors of high BC mortality in Africa. This review aimed to appraise the contributing factors to delayed breast cancer presentation and diagnosis among SSA women.
Five databases encompassing medical and social sciences were systematically searched using predefined search terms linked with breast cancer presentation and diagnosis and sub Saharan Africa. Reference lists of relevant papers were also hand searched. Quality of quantitative and qualitative articles were assessed using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the Critical Appraisal Skills Programme (CASP) quality appraisal checklist. Thematic analysis was used to synthesize the qualitative studies to integrate findings.
Fourteen (14) quantitative studies, two (2) qualitative studies and one (1) mixed method study merited inclusion for analysis. This review identified low knowledge of breast cancer among SSA women. This review also found lack of awareness of early detection treatment, poor perception of BC, socio-cultural factors such as belief, traditions and fear as factors impacting African women’s health seeking behavior in relation to breast cancer.
Improving African women’s knowledge and understanding will improve behaviors related to breast cancer and facilitate early presentation and detection and enhance proper management and treatment of breast cancer.
Incidence and mortality rates for cancer has increased over the second half of the 20th century and are likely to continue to surge substantially according to World Health Organization (WHO) projections [
Variation in incidence rates may largely stem from greater availability of early detection measures as well as health seeking behaviors of women in developed countries [
Studies undertaken in Africa suggest low knowledge of breast and cervical cancer awareness [
The disparity in BC outcomes in women living in developing and developed countries provides the momentum for this paper to review research on barriers to early presentation and diagnosis of BC in women from Africa. This review is also relevant as barriers may not be limited to early presentation for BC alone. Findings from this review can potentially aid in drafting measures to improve the knowledge and health seeking behaviors of African women. This review was conducted with the aim to synthesize research evidences on the barriers to early presentation and diagnosis of breast cancer among women in sub-Saharan Africa.
A comprehensive search strategy was developed to find published studies on BC knowledge and health seeking behaviors of women in sub Saharan Africa. The sub Saharan region was classified based on the United Nations classification of countries [
Studies that were included in this review were of any design (qualitative and quantitative) published in English language peer-reviewed journals, and primary research articles, that identified barriers to early presentation and diagnosis of BC in women of African descent living in Africa. This included studies that explored knowledge of BC, studies of attitudes or barriers to breast screening, studies that explored attitude to and undertaking of breast self-examination (BSE). Studies that explored health seeking behaviors regarding BC, factors affecting women’s return for follow-up following abnormal test results, diagnostic delays due to service-related factors after suspicious findings by health professionals and studies of African women and women from other ethnic groups, but reported on findings for the included ethnic groups separately were also included.
Excluded articles consisted of those that included African women and women from other ethnic groups within the overall sample, but did not report on findings for the included ethnic groups separately. Studies that reported research carried out in Western countries, only reported differences in time to presentation/diagnosis by race and did not explore factors accounting for these differences, only described interventions in relation to increasing uptake of cancer screening and/or improving early presentation/detection rates were also excluded. African women’s perceptions of cancer without information on early presentation and diagnosis were excluded.
Data were extracted systematically from all eligible papers through the use of standardized Data Extraction Forms (DEFs) developed by a research team [
The quality of the quantitative studies was assess based on National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies [
Findings from qualitative and quantitative articles were integrated into themes. Thematic synthesis of the qualitative studies [
The flow of information through the various stages of the review is represented in
Nine (9) of the quantitative articles were descriptive cross-sectional surveys [
Authors, country of study | Methods | Participants/ |
Findings | Quality |
---|---|---|---|---|
Focus group Interview, framework analysis | Females rural & urban, Kenyans (20-60years) | Good | ||
• ↓ level of awareness in BC |
||||
Sampling: Convenience/purposive | ||||
Size: 6–7 in 4 groups | ||||
• Wrong perception of early detection benefits | ||||
In-depth interviews | Breast cancer patients | Good | ||
Sampling: Purposive | (>18years), Urban | • ↓ knowledge of BC prior to diagnosis | ||
Size: 12 | ||||
• Health practitioners lack of seriousness about breast cancer |
Authors | Methods | Participants | Findings | Quality |
Cross-sectional, interview administered questionnaire, SPSS Sampling: Convenient, Purposive; Size: 1194 | Females Nigerians, Rural (20-45years) | Fair | ||
Cross-sectional survey, interview administered questionnaire, x2 analysis; Sampling: Random; Size: 393 | Females doctors, nurses, pharmacists, lab scientists, radiologist, Nigerians (>20years) | Good | ||
Cross-sectional survey, interview administered questionnaire, SPSS, x2 analysis Sampling: Purposive; Size: 281 | Females traders Nigerians (16–80years) | Fair | ||
Survey, interview administered questionnaire; Sampling: Convenience purposive; Size: 101 | Females Ghanaians (20-84years) | Fair | ||
Correlational survey. Self-administered questionnaire, Pearson x2, Spearman’s rho; Sampling: Convenience purposive; Size: 565 | Females, South African women (>18years) | Fair | ||
Cross-sectional survey, interview administered; Sampling: Random; Size: 1000 | Females semi-urban community (15-91years) | Good | ||
Survey, interview administered questionnaire Sampling: Multistage random; Size 420 | Females, rural setting (20–60years) | Fair | ||
Survey, interview administered, x2 multivariate & 3-way analysis of variance Sampling: Random Size 140 | Females, rural and urban setting (21-59years) | Fair | ||
Cross-sectional Sampling: All patients studied; Size: 201 | Breast cancer patients, Urban; (23-104years) | Good | ||
Cross-sectional, standardized questionnaire; Sampling: Convenient and consecutive; Size: 120 | Adults > = 20years, Semi-Urban | Good | ||
Cross-sectional; Sampling: Purposive, stratified and simple; Size: 365 | Women in reproductive age (19-49years), |
Fair | ||
Quantitative survey; Sampling: Convenient; Size: 299 | Women presenting at CC and BC prevention &screening project, (> = 18 years), Rural | Fair | ||
Quantitative survey; Sampling: Convenient; Size: 299 | Outpatients at government-supported hospitals (18-55years), Urban | Good | ||
Cross-sectional; Sampling: All participants; Size: 365 | 159 (144 involved in analysis) | Good | ||
Cross-sectional; Cluster and systematic sampling; Size: 500; Quantitative -474 | General population (40-70years), Urban | Good |
A total of 6681participants were recruited and involved in the14 included quantitative studies. The least number of participants in a study was 110 women [
Several barriers to early presentation and diagnosis of BC were reported across all studies.
Barriers | Number of studies (n = 17) | Percentage |
---|---|---|
• Limited knowledge of BC | 13 | 76.4 |
• Limited knowledge of screening practices (BSE, CBE, mammography) | 5 | 29.4 |
• Misconceptions, misinformation, lack of information | 8 | 47.1 |
8 | 47.1 | |
• Limited screening facilities in community | 1 | 5.8 |
• Poor health attitude | 1 | 5.8 |
3 | 17.6 | |
• Age | 2 | 11.8 |
• Education | 4 | 23.5 |
• Marital status | 1 | 5.8 |
• Residence | 1 | 5.8 |
• Pre-menopausal | 1 | 5.8 |
• Fear of cancer diagnosis, death, stigma, diagnosis procedure | 5 | 29.4 |
• Belief in other sources of treatment | 4 | 23.5 |
• Gender roles and household decision making | 1 | 5.8 |
Reasons | Pace et al [ |
Opoku, Benwell &Yarney [ |
Azubuike &Okwuokei [ |
Ibrahim & Oludara [ |
Okobia et al [ |
Clegg-Lamptey et al |
Muthoni& Miller [ |
---|---|---|---|---|---|---|---|
Not bothered to check | x | ||||||
Ignorance of nature of disease | x | x | x | x | |||
Financial constraints | x | x | x | x | x | ||
Belief in alternative treatment | x | x | |||||
Busy/forgot | x | x | |||||
Fear of having cancer/death | x | x | x | x | x | ||
Fear of stigma | x | ||||||
Unaware of appropriate facilities / procedures | x | x | x | x | |||
Health Inaccessibility | x | ||||||
Fear of being examined (unwilling to expose body) | x | x | x | ||||
Not referred | x | ||||||
Fear of procedure | x | x | x | ||||
Attitude of health staff | x | ||||||
Culture interferences | x |
Majority of the studies (15) reported lower participants’ knowledge of the causes, symptoms, early detection and treatment of BC [
Awareness of BSE and CBE were reportedly very low in some studies [
Some studies showed that participants with higher educational attainment were more knowledgeable about BC issues than those with lower levels of education and or had no formal education [
The sources of respondent’s information on BC were investigated in some studies [
Source | OKobia et al, 2006 [ |
Oluwatosin&Oladepo, 2006 [ |
Maree & Wright 2010 [ |
Opoku, Benwell & Yarney, 2012 [ |
Morse [ |
---|---|---|---|---|---|
Healthcare professionals | 21.1% | 4.4% | 6.75 | 13.9% |
7.1% |
Primary healthcare | - | - | 30.7% | - | - |
Cancer awareness group | 6.0% | - | 3.9% | - | - |
Feminist organisation group | 6.7% | - | - | - | - |
Supervisors of breast cancer | - | 5.2% | - | 4.7% | - |
Television | 31.0% | 5.4% | 13.9% | - | |
Radio | - | - | 20.6% | 20.5% | 36.4% |
Leaflets/newspaper | 27.1% | - | - | 39.8% | 0.9%/1.8% |
Elders/Friends/Neighbours | - | 15.4% | - | 5.1% | 8.9% |
Church /Religious organisation | 8.1% | - | - | 6.5% |
- |
Family members | - | - | - | 7.8% | - |
*Nurses and midwives
**doctors
Varied perceptions of BC were also reported across studies. A large number of participants perceived BC as very serious form of cancer [
The review revealed poor health seeking behaviors among women in SSA and this influence the early presentation and diagnosis of breast cancer. Poor health seeking behaviors were as a result of socio-cultural factors, fear of being diagnosed cancer and death from cancer, as well as traditional practices,
A study, [
Fear was reported as a contributing factor for women’s failure to seek treatment for BC [
The fear, stigma and cost involved in diagnosis and treatment in Africa compels women to seek for alternative source of BC care including traditional healer and or herbalist. Pace et al., [
Okobia et al, [
Socio-demographic characteristics such as age, marital status, women education and type of residence was reported as impediments to BC treatment. Age as a barrier to late presentation was described by [
Barriers owing to inadequate screening programs, attitude of health personnel’s and access to healthcare were also intimated to contribute to late presentation of BC. Difficulty in accessing healthcare as a result of living in a remote area and the lack of seriousness of health professionals about BC was shown to be a barrier to early presentation [
Authors rated majority of the studies to be of good or high quality based on our assessment criteria [
This review sought to identify health seeking behaviors and other contributing factors to delays in BC detection among African women. We identified knowledge gap as an important contributing factor for late presentation and early detection measures. Knowledge is an important determinant of healthcare utilization and this association has been previously established. Studies also reveal that this barrier to BC treatment and management is not only evident among African women but also in other developed countries including UK, USA, Canada, Hong Kong and India where an association between poor knowledge and health literacy with late detection of BC and case presentations persist [
In some African countries discrepancies exist between the knowledge of participants in urban and rural settings. Whereas urban middle-income women identified lifestyle factors such as stress, sedentary behaviour, and dietary factors as possible risk factors for BC, rural women indicated, remnants of milk retained in the breast, keeping money or a mobile telephone inside their braziers, witchcraft, evil spirits and punishment from the gods as factors contributing to BC [
There is evidence from this review that women in Africa have a low level of knowledge on early detection measures for BC, which appears to affect their practices and involvement. The combined effect of poor knowledge of early detection measures and low health literacy has been identified as influencing the disease in some developed countries [
What is of much concern in sub Saharan Africa is the availability of accurate health information. Sources of information determines how accurate the information is, and these information shapes their perception and beliefs about breast cancer, its causes and the need to participate in screening and other important preventive practices. A study undertaken among urban residents in Chicago [
Studies reported that, most women received BC information mainly from television (31%), clinics (31%) and health professionals (21%) [
This prompt the need for educational campaigns among African women to enhance their knowledge of BC and benefits of early detection and treatment. The Breast Health Global Initiative (BHGI) [
Decision to seek medical attention was found to be a barrier to early BC diagnosis and presentation in this review. This is shaped by the women’s preferences for alternative treatment. A study reported that only 29% indicated their preparedness to seek medical attention upon identifying such signs and symptoms whereas others prefer traditional treatment (46%) for BC care [
Sociocultural factors such as influence of husbands and partners were also important in determining early detection and treatment. The influence of societal factors on access to healthcare is also mediated through their opportunities to education, income, occupation, control over earnings and participation in decision-making. Gender norms and values of women in society determine their status within the household and the community at large, and influence their access to healthcare [
Access difficulties, long distances and residing in remote areas pose difficulties for women with respect to access to BC diagnosis and treatment. Living in rural areas is associated with greater distances and high cost of transport to access healthcare services [
The strength of this review reflects the various themes identified and their consistency with studies from other developed countries on the subject area [
Generally, knowledge inadequacy of BC and its early detection measures continue to be one of the most important factors in determining women’s attitude towards BC screening and treatment. Understanding the benefits of early detection and presentation of BC among women was poor across all studies. Sources of information, knowledge of early detection measures, sociocultural beliefs and traditions revealed women’s perceptions of BC. Societal traditions and beliefs play an important role in women’s BC perceptions, screening measures and treatment. The findings of this study prompt educational campaigns among African women to enhance their knowledge of BC, benefits of early detection and treatment.
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