Result of randomized control trial to increase breast health awareness among young females in Malaysia

Awareness about Breast Cancer and Breast Self-Examination among Undergraduate Female Students at the University of Agadir, Morocco: A Cross-Sectional Descriptive Study

Breast cancer is a pressing public health issue globally and in Morocco, with rising cases among women. This study aims to evaluate breast cancer awareness and self-examination practices among female university students, informing future educational interventions. A cross-sectional study surveyed 437 students at Ibn Zohr University, Agadir, using a questionnaire covering demographics, knowledge of breast cancer, risk factors, symptoms, and breast self-examination (BSE). Results showed high awareness of breast cancer (95.3%), with social networks and media being primary information sources. However, only 48.25% had intermediate knowledge levels, and BSE awareness was moderate (60.8%) with low practical skills (28.0%). Reasons for not performing BSE included lack of knowledge and discomfort. Significant associations were found between knowledge levels and age, year of study, study options, and information sources. Despite high awareness, there is a crucial need to enhance knowledge about breast cancer risk factors, symptoms, and BSE practices among young women in Morocco. Educational programs targeting university students are essential for promoting early detection and improving attitudes toward breast health.

The effect of counseling based on health promotion awareness on self-care needs and reproductive and sexual health literacy of newly married women: a randomized controlled clinical trial study

BACKGROUND

Despite the importance of health literacy and the self-care skills in improving individual and social health and health costs reduction, scientific evidence indicates women's poor awareness of self-care needs and low health literacy concerning reproductive and sexual health in most societies. The present study was conducted to specify the effect of health awareness promotion on self-care needs and reproductive and sexual health literacy of newly married women.

METHODS

This randomized controlled clinical trial was conducted on 64 newly married women aged 15-45 in Tehran, Iran from August 2021 to the end of December 2021. The participants were randomly assigned into the intervention (n = 32) and control (n = 32) groups. The intervention group received four individual health awareness-promotion education sessions. The reproductive and sexual self-care needs, and sexual health literacy questionnaires, were completed before and 4-week after the intervention through interview. The data were analyzed using SPSS26 software. The independent t-tests and ANCOVA were used to comparison the mean scores and a significance level of P < 0.05 was considered.

RESULTS

The results of this study indicated that after counseling, the average overall score of perceived reproductive and sexual self-care needs significantly decreased in the intervention group [Mean (standard deviation(SD)): 125.70 (24.70)] compared to the control group [Mean (SD): 87.1 (23.42)][P = 0.001]. Also, the mean score of sexual and reproductive health literacy significantly increased in the intervention group [Mean (SD): 125.50 (14.09)] compared to the control group [Mean (SD): 97.15 (14.90)] after intervention [P = 0.01].

CONCLUSIONS

The results indicated the positive effect of health promotion awareness educations on reproductive and sexual self-care needs and health literacy among newly married women. Therefore, health promotion interventions should be incorporated in health services provision programs for newly married women in comprehensive health centers to improve the health of women and families.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT): IRCT20171007036615N7 Date of registration: 2021-09-21. URL: https://fa.irct.ir/trial/58597 .

Women's Knowledge, Attitudes, and Perception on Personalized Risk-Stratified Breast Cancer Screening: A Cross-Sectional Study in Malaysia

AIM

Breast cancer is commonest cancer among Malaysian women and screening is essential for the early detection. Therefore our study aimed at measuring the levels of knowledge, attitude and perception towards personalized risk stratified breast cancer screening in Malaysia.

METHODS

A cross-sectional study was carried out in Malaysia to assess the knowledge, perception and attitudes of the women in Malaysia. The study was conducted using an online questionnaire, and samples were obtained using convenience sampling. The questionnaire was distributed trilingual in English, Bahasa Malaysia and Chinese. The data was collected with content validated questionnaire. Data was analyzed with descriptive statistics and General Linear Model analysis in SPSS (Version 27).

RESULTS

A total of 201 respondents' data were analyzed. From our study we were able to summarize that the women in Malaysia have a suboptimal knowledge towards personalized risk-stratified breast cancer screening as only 48.9% aware of the term for personalized risk-stratified breast cancer screening. Meanwhile, the majority of the respondents (96.7%) showed positive attitudes towards the importance of risk assessment and screening. Experience of participating in health education programmes about breast cancer and personalized risk-stratified screening was found to be significantly associated with knowledge, attitude and perception towards personalized risk-stratified breast cancer screening.

CONCLUSION

General population's awareness of individualized risk-stratified breast cancer screening was insufficient despite their favourable attitude towards the disease. A multimodal strategy may be used to improve women's knowledge, attitude, and perception of individualized risk-stratified breast cancer screening.

Feasibility of monitoring Global Breast Cancer Initiative Framework key performance indicators in 21 Asian National Cancer Centers Alliance member countries

Background

The Global Breast Cancer Initiative (GBCI) Framework, launched by the World Health Organisation (WHO) in 2023, emphasises assessing, strengthening, and scaling up services for the early detection and management of breast cancer. This study aims to determine the feasibility of monitoring the status of breast cancer control in the 21 Asian National Cancer Centers Alliance (ANCCA) countries based on the three GBCI Framework key performance indicators (KPIs): stage at diagnosis, time to diagnosis, and treatment completion.

Methods

We reviewed published literature on breast cancer control among 21 ANCCA countries from May to July 2023 to establish data availability and compiled the latest descriptive statistics and sources of the indicators using a standardised data collection form. We performed bivariate Pearson's correlation analysis to measure the strength of correlation between stage at diagnosis, mortality and survival rates, and universal health coverage.

Findings

Only 12 (57%) ANCCA member countries published national cancer registry reports on breast cancer age-standardised incidence rate (ASIR) and age-standardised mortality rate (ASMR). Indonesia, Myanmar, and Nepal had provincial data and others relied on WHO's Global Cancer Observatory (GLOBOCAN) estimates. GLOBOCAN data differed from the reported national statistics by 5-10% in Bhutan, Indonesia, Iran, the Republic of Korea, Singapore, and Thailand and >10% in China, India, Malaysia, Mongolia, and Sri Lanka. The proportion of patients diagnosed in stages I and II strongly correlated with the five-year survival rate and with the universal health coverage (UHC) index. Three countries (14%) reported national data with >60% of invasive breast cancer patients diagnosed at stages I and II, and a five-year survival rate of >80%. Over 60% of the ANCCA countries had no published national data on breast cancer staging, the time interval from presentation to diagnosis, and diagnosis to treatment. Five (24%) countries reported data on treatment completion. The definition of delayed diagnosis and treatment completion varied across countries.

Interpretation

GBCI's Pillar 1 KPI correlates strongly with five-year survival rate and with the UHC index. Most ANCCA countries lacked national data on cancer staging, timely diagnosis, and treatment completion KPIs. While institutional-level data were available in some countries, they may not represent the nationwide status. Strengthening cancer surveillance is crucial for effective breast cancer control. The GBCI Framework indicators warrant more detailed definitions for standardised data collection. Surrogate indicators which are measurable and manageable in country-specific settings, could be considered for monitoring GBCI indicators. Ensuring UHC and addressing health inequalities are essential to early diagnosis and treatment of breast cancer.

Funding

Funding for this research article's processing fee (APC) will be provided by the affiliated institution to support the open-access publication of this work. The funding body is not involved in the study design; collection, management, analysis and interpretation of data; or the decision to submit for publication. The funding body will be informed of any planned publications, and documentation provided.

Cancer Stigma Among 800 Saudi Citizens: A Cross-Sectional Study and Literature Review

INTRODUCTION

Cancer-related stigmatization is a noteworthy phenomenon, yet it has not received sufficient attention in public health studies. Despite recent advancements in treatment and improvements in survival, the burden of stigma remains a challenging concern for individuals diagnosed with cancer.

AIM

This study aims to assess the presence of cancer stigma in the Saudi Arabian population by using the Cancer Stigma Scale (CASS).

METHODS

A cross-sectional study was conducted among the general population of Saudi Arabia. Data collection was facilitated through a self-administered online questionnaire, incorporating socio-demographic variables such as age, gender, and regional residence and employing the CASS instrument to gauge the prevalent attitudes and stigmas related to cancer.

RESULTS

Out of the 874 participants, a majority of 87.1% were female, with 60.2% aged between 20 and 39 years. Notably, 59% reported having a close friend or family member diagnosed with cancer. The average CASS score stood at 1.59 (SD 0.39) on a 5-point scale, with an overwhelming 97.1% registering scores under 2.5, suggesting a generally low stigma perception. In dissecting the CASS components, 'severity' recorded the highest mean score (mean: 2.23), followed by 'awkwardness' (mean: 1.86) and 'financial discrimination' (mean: 1.71). 'avoidance' registered the lowest mean score at 1.11. Notably, a trend of increasing stigma was observed with advancing age, and male respondents indicated a marginally higher propensity towards stigmatizing attitudes.

CONCLUSION

In Saudi Arabia, cancer-related stigma is generally low. However, 'severity' is the most prominent stigma aspect, with 'avoidance' being the least. Older individuals and males exhibit slightly higher stigmatizing attitudes. These insights highlight the need for targeted public health efforts to address remaining stigmatization, especially based on age and gender.

The impact of an online educational game on breast cancer awareness among university female students, Malaysia: a pilot study

BACKGROUND

Breast cancer is one of the world's most prevalent cancer and the most common type of cancer in Malaysia. Interestingly, breast cancer in young women is more aggressive compared to older women and the survival rate among these groups of individuals is poor. Thus, breast cancer awareness is essential among young women as early detection is possible and treatment will be effective during which the disease is curable. Hence, the purpose of this study is to design and evaluate the impact of an educational game on breast cancer awareness among female university students in Malaysia.

METHODS

This is a one-group pre-and post-intervention pilot study. It was conducted in Private and public higher education institutions around Malaysia. An online education game was created and used as the intervention. A self-administered questionnaire was administered to the participants during the pre-and post-intervention test to evaluate the online educational game on breast cancer awareness.

RESULTS

A total of 52 responses were collected. The mean age of the participants was 21.98 (SD = 1.896) years. The findings showed a statistically significant median increase (p < 0.05) in breast cancer knowledge scores among participants in the post-intervention. A median increase in breast cancer knowledge score of 6 was shown when participants were exposed to the online education game (24.00) compared to before they were exposed to it (17.00).

CONCLUSION

Using online educational games effectively raised awareness of breast cancer among university students. Online games can be used as a health educational tool to promote awareness of a topic of interest, as digital games can be accessed easily, game content can be tailored made or updated, and improve participant engagement in learning.

Effects of Information Provided to University Students Through an Educational Brochure on Health Beliefs and Testicular Self-Examination

This study aimed to examine the effect of an educational brochure about testicular cancer and its early diagnosis on the health beliefs and self-examination of participants. The pretests/posttests were conducted in a quasi-experimental design with non-randomized groups and a control group of university students. The study recruited students enrolled in the psychological counseling and guidance department of a Turkish public university. The research sample comprised 92 students, 48 in the experimental and 44 in the control group. An educational brochure about testicular cancer and self-examination was provided to the experimental group. The data includes a personal information form, testicular cancer and health beliefs scale about testicular self-examination, and the form for self-examination. Mann Whitney U, Wilcoxon, and chi-square analyses were performed for data analysis. A significant difference was found between the scores of the experimental and control groups regarding seriousness/caring, benefit and health motivation, obstacles, and self-efficacy (p < 0.05). Moreover, the testicular self-examination ratio was determined as 83.3% in the experimental group and 4.5% in the control group. It can be asserted that the training brochure is effective in promoting the self-examination of testicles. It may be recommended to conduct experimental studies with larger study groups to increase testicular self-examination.

Details of Cancer Education Programs for Adolescents and Young Adults and Their Effectiveness: A Scoping Review

The purpose of this review was to establish what cancer education programs have been carried out aimed at adolescents and young adults (AYAs) and what outcomes they achieved. The databases used were MEDLINE, CINAHL, and Web of Science, and the search period was set as 2011-2020. The extracted literature was evaluated for quality using the Joanna Briggs Institute's critical appraisal tools. The subjects of the analysis were 29 studies: 10 randomized controlled trials and 19 quasi-experimental designs. Regarding the varieties of cancers found in the data, in descending order, 10 documents looked at cervical cancer, 9 looked at cancer in general, and 4 looked at breast cancer. Most studies focused on AYAs exclusively, with just three studies involving their parents simultaneously. Many studies used lecture-based intervention, with information technology-based interventions using websites and cell phones. Topics included in the program were cancer epidemiology, cancer risk factors, cancer warning signs and symptoms, prevention methods, and screening methods. After the intervention, all studies showed statistically significant improvements in at least one outcome measure, which included knowledge and awareness of cancer, health beliefs, and intent to take preventive action, demonstrating a basis for educational intervention. Educating AYAs about cancer at a time when their ways of life are becoming more concrete can be expected to have a positive impact on cancer preventing behaviors in adulthood, increase their parents' awareness of cancer, and have a positive impact on behavior around screening.

Psychotherapeutic intervention on breast self-examination based on Health Belief Model

The aim of this research was to verify the effectiveness of a Health Belief Model-based intervention in increasing knowledge and changing beliefs about breast cancer and its early detection as well as in improving breast self-examination behaviors. This randomized controlled clinical trial involved 210 women. The program was implemented by email and involved sending daily messages to participants for 30 days. The women in the intervention group received messages aimed at increasing the practice of breast self-examination behavior. Participants in the control group received messages promoting general health. Before and after the intervention there were evaluated the application of breast self-examination, level of knowledge, beliefs associated with health (susceptibility to develop breast cancer, disease severity, benefits of self-examination, barriers to achieving this behavior, cues to action, self-efficacy in performing self-examination). At the end of the program, a significant improvement in the perception of disease severity and the benefits of breast self-examination was obtained, as well as a significant increase in the percentage of participants who achieved this behavior. The results obtained are arguments for it to be implemented by health care providers who want to promote self-examination as a method of early detection of breast cancer.

Factor structure and internal reliability of breast cancer screening Champion's Health Belief Model Scale in Yemeni women in Malaysia: a cross-sectional study

BACKGROUND

The reliability and validity of the Champion's Health Belief Model Scale (CHBMS) used in assessing the belief of women regarding breast cancer (BC) and breast cancer screening (BCS) have been examined on various populations. However, the use of this tool has not been adequately assessed for its validity in ethnic minorities. This study assessed the validity and reliability of CHBMS by analyzing the factor structure and internal reliability of the factors among Yemeni women in Malaysia.

METHODS

A survey was conducted among 103 female teachers from 10 schools. SPSS version 22.0 was utilized in analyzing the data. Descriptive statistics were computed for the socio-demographic characteristics. The Cronbach's alpha coefficients were used in assessing the internal reliability. The Exploratory Factor Analysis (EFA) was used to analyze the factor structure of the translated items. Parallel analysis was performed to determine the number of factors accurately.

RESULTS

The alpha coefficients of the factors had acceptable values ranging between 0.76 and 0.87. The factor analysis yielded six and five factors for breast self-examination (BSE) and mammography (MMG), with a total explained variance of 47.69% and 52.63%, respectively. The Kaiser-Meyer-Olkin (KMO) index values of 0.64 and 0.72, and the Bartlett's Test of Sphericity (P = 0.0001) for BSE and MMG, respectively, verified the normality distribution and the adequacy of the sample size for EFA. All the items on each factor were from the same construct that were consistent with the number of factors obtained in the scale development study. The items achieved adequate factor loadings that ranged between 0.47 and 0.88.

CONCLUSIONS

The translated version of the CHBMS is a validated scale used in assessing the beliefs related to BC and BCS among Yemeni women living in Malaysia. Healthcare workers could use the scales to assess women's beliefs on BC and BCS. This instrument could be used to test the effectiveness of the intervention programs.

Relationship between demographic factors, health education, breast cancer-related knowledge, attitudes, and breast self-examination behavior among Chinese female college student: A structural equation analysis

AIMS

This study aimed to create a structural equation model to evaluate the associations among demographic factors, health education, breast cancer-related knowledge, attitudes, and breast self-examination behavior among Chinese female college students.

METHODS

A survey was undertaken using a self-administered questionnaire and targeting 2233 students from Eastern China. Structural equation modeling with the bootstrap approach was utilized to estimate the interrelationships and the strength of the associations among measured variables based on the hypothetical model.

RESULTS

Among the total participants, 14.7% of the female college students reported having performed breast self-examination. The final structural equation model showed highly satisfactory fitness on indices. Breast self-examination behavior was significantly linked to demographic factors, breast cancer related-knowledge, attitudes, and health education. Health education had the greatest influence on breast self-examination behavior. In addition, breast cancer related-knowledge was significantly associated with demographic factors and health education. Health education and knowledge all significantly affected attitudes towards breast cancer.

CONCLUSION

Breast self-examination behavior was influenced by demographic factors, breast cancer related-knowledge, attitudes towards breast cancer, and health education in a sample of female college students in China. Health education was the most important predictor of breast self-examination behavior.

The effect of a smartphone application on women's performance and health beliefs about breast self-examination: a quasi-experimental study

BACKGROUND

Breast Self-Examination (BSE) is a simple and inexpensive method for early diagnosis of breast cancer. This study aimed to determine the effect of a smartphone application on women's performance and health beliefs regarding BSE.

METHODS

In this quasi-experimental study, 150 women referring to therapeutic clinics in Jahrom, Iran from December 2019 to May 2020 were randomly assigned to an intervention or a control group. The intervention group participants had access to a smartphone application including BSE reminder, training, alarm, and feedback to the therapist. The application also contained educational movies and self-assessment. The study data were collected using Champion's Health Belief Model Scale and BSE information record form before and six months after the intervention. Then, the data were entered into the SPSS 21 software and were analyzed using descriptive statistics, paired t-test, independent t-test, Chi-square, ANCOVA, Mann-Whitney, and Wilcoxon tests.

RESULTS

After the intervention, the largest number of BSEs was four times among 60% of the participants in the intervention group and once among 24% of the participants in the control group during four months (p = 0.001). After the intervention, the mean differences of the scores of perceived susceptibility (1.03 ± 2.65 vs. 0.01 ± 0.42, p = 0.001), BSE barriers (2.80 ± 5.32 vs.  0.04 ± 1.43, p = 0.001), self-efficacy (10.75 ± 7.63 vs. - 2.75 ± 2.44, p = 0.001), and health motivation (2.77 ± 3.70 vs. - 0.29 ± 0.63, p = 0.001) were significantly higher in the intervention group compared to the control group. However, no significant difference was observed between the two groups with regard to perceived severity and BSE benefits after the intervention.

CONCLUSIONS

Access to the smartphone application enhanced the participants' performance and health beliefs regarding BSE in the areas of perceived susceptibility, self-efficacy, and health motivation. Therefore, we recommend using the same smartphone application to improve women's performance and health beliefs regarding BSE.

Effect of health belief model on flood-risk educational approach among elementary school children in Malaysia

Worsening climatic conditions can subsequently lead to the frequent occurrence of unpredictable natural disasters. The early-life educational approach is one of the non-structural mitigations in disaster management, which are the most effective efforts to promote early-life disaster awareness and enhance the knowledge transfer in disaster risk education. By using the health belief model (HBM), this study aims to examine the effectiveness of HBM on the flood-risk reduction (FRR) educational intervention by looking into the perceived susceptibility, severity, benefit and self-efficacy among elementary school children in Malaysia. This study utilised the one-group pre-test-post-test design by recruiting 224 elementary school children in the pre-FRR educational intervention programme, and 205 who undertook a post-intervention programme a month later. This study showed that the FRR educational intervention significantly improved (p < 0.001) the overall HBM components during the post-intervention, particularly in: (1) FRR knowledge, (2) perceived susceptibility, (3) perceived severity and (4) perceived benefits. The one-way analysis of covariance test showed that knowledge transfer intervention is effective to improve all the HBM components that include (1) FRR knowledge, F(38,127) = 2.517; (2) perceived susceptibility, F(6,191) = 6.957; (3) perceived severity, F(20,163) = 2.944; (4) perceived benefits, F(25,153) = 2.342 and (5) self-efficacy, F(7,189) = 12.526. The impact of integrating HBM into knowledge transfer intervention was seen to be effective and provide a positive knowledge enhancement among learners. Therefore, it is crucial to implement a consistent and sustainable educational intervention to harness formal education for community resilience at an early age.

Educational interventions on breast cancer in men and women: a necessity in primary healthcare

Breast cancer (BC) is one of the most common diseases in the global population. It most commonly presents in women; however, there has been an increase in the number of men diagnosed with the disease, although at a lower rate. Its specific characteristics and associated risk factors mean that preventative measures are considered to be one of the most important methods of avoiding BC. Therefore, education is a fundamental part of this process. The objective of this study is to report on the educational interventions on BC carried out in healthcare between 2016 and 2021. To this end, an integrative review was carried out using the following databases: PubMed (NCBI), Science Direct, Scopus, SciELO and Google Scholar, using the keywords 'breast cancer', 'intervention education', 'prevention' and the Boolean operator 'AND'. Quantitative, full-text articles in English, Spanish or Portuguese were included. Finally, 19 articles were selected for analysis and it was found that, with regard to educational interventions on BC carried out in healthcare, one article included men and women and the remaining 18 included only women, with interventions carried out in sessions, workshops, in stages and using dynamic techniques. Therefore, there is a pressing need for educational interventions on BC for men and women at all stages of life; however, priority should be given to the young population in order to allow for early prevention. These interventions do not generate costs for the health sector, but they have a positive effect by increasing knowledge and promoting self-care.

Evaluation of an Intervention Program for Promoting Breast Self-Examination Behavior in Employed Women in Iran

Introduction:

Breast cancer is the most common malignancy in the world. Screening is the basis for early detection. However, the mortality rate is still high in Iranian women related to not screening and timely check-ups. We offered a theory-based intervention program to improve breast cancer screening behavior in women.

Methods:

This interventional study was conducted in 135 employed women in 2019. Their screening behavior was investigated using a questionnaire based on the Protection Motivation and Social Support Theories. We compared the efficacy of 2 educational interventions (a workshop and an E-learning program) between 2 intervention groups and a control group. The results were collected 3 months after the interventions had taken place. Data were analyzed in SPSS 23 using descriptive statistics, chi-square, analysis of variance (ANOVA), and the paired sample t-test.

Results:

We found a significant difference between the mean score of knowledge and the theoretical constructs (P value < .001) before and after the interventions. Our results also showed that both the intervention methods had a similar effect and that there was a significant difference in the performance of breast self-examinations between the intervention and control groups after the intervention (P value < .001).

Conclusion:

Given the cost-effectiveness and feasibility of implementing an E-learning program, we would recommend that health care planners assist in designing and implementing this effective form of intervention to encourage many more women to perform self-examinations to aid breast cancer screening.

The Effectiveness of Educational Interventions on Breast Cancer Screening Uptake, Knowledge, and Beliefs among Women: A Systematic Review

There have been various systematic reviews on the significance of educational interventions as necessary components to encourage breast cancer screening (BCS) and reduce the burden of breast cancer (BC). However, only a few studies have attempted to examine these educational interventions comprehensively. This review paper aimed to systematically evaluate the effectiveness of various educational interventions in improving BCS uptake, knowledge, and beliefs among women in different parts of the world. Following the PRISMA guidelines, a comprehensive literature search on four electronic databases, specifically PubMed, Scopus, Web of Science, and ScienceDirect, was performed in May 2019. A total of 22 interventional studies were reviewed. Theory- and language-based multiple intervention strategies, which were mainly performed in community and healthcare settings, were the commonly shared characteristics of the educational interventions. Most of these studies on the effectiveness of interventions showed favorable outcomes in terms of the BCS uptake, knowledge, and beliefs among women. Educational interventions potentially increase BCS among women. The interpretation of the reported findings should be treated with caution due to the heterogeneity of the studies in terms of the characteristics of the participants, research designs, intervention strategies, and outcome measures.

Effects of Counselling on Quality of Life among Cancer Patients in Malaysia: A Randomized Controlled Trial

Background

We aimed to assess whether "Managing Patients on Chemotherapy" book is effective to improve quality of life (QOL) of cancer patient via counselling by pharmacist.

Methods

A randomized control trial study was run among 2120 cancer patients in public hospitals in Peninsular Malaysia, from Apr 2016-Jan 2018. The treatment group received counselling regarding chemotherapy by using developed module. The data were collected at three time-points: baseline, 1^st, 2^nd and 3^rd follow-ups after counseling by Validated Malay version of the WHOQOL-BREF of questionnaire. Data analyses were done using χ² and two-way repeated measure ANOVA.

Results

The treatment group improved significantly as compared to control group in physical health, psychological health, social relationship, environment and overall QOL (P<0.00).

Conclusion

The "Managing Patients on Chemotherapy" book along with repetitive counselling by pharmacists is a useful intervention for improving QOL of cancer patients undergoing treatment.

Interventions Addressing Barriers to Delayed Cancer Diagnosis in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Delays to cancer diagnosis exist, resulting in worse survival outcomes for many cancers. Interventions targeting delays and barriers to cancer diagnosis and treatment have been investigated, but mostly in high-income countries. We conducted a systematic literature review to identify and characterize the interventions studied across cancers, within low- and middle-income countries (LMICs).

METHODS

This systematic review forms part two of a wider study examining solutions to delays and barriers in cancer early diagnosis in LMICs. A comprehensive literature search was conducted on November 27, 2017, encompassing published studies from the preceding 15 years. We extracted study design, population, and intervention, and reported outcome measures from each study. Results were presented by target of interventions (general vs. health care professionals). A narrative synthesis was used to summarize intervention efficacy.

RESULTS

Of 10,193 abstracts returned, 25 were included, consisting of studies across World Health Organization geographical regions, examining breast, cervix, childhood, prostate, head and neck, and gastric cancers. Altogether, 11 intervention studies targeted the general population, 12 targeted health care professionals, and 2 targeted both. The majority (17/25) of studies reported interventions focusing on patient and diagnosis-related barriers early in the cancer care pathway. Most studies reported knowledge score as primary outcome measure (17/25); few (6/25) reported on clinically relevant measures such as reducing disease stage at presentation or diagnostic time interval. Effectiveness of interventions was demonstrated for some cancers only.

CONCLUSION

More interventions reporting clinically relevant measures and using standardized methods and outcomes are required to improve our ability to effectively improve cancer early diagnosis in LMICs.

IMPLICATIONS FOR PRACTICE

Prior to this study, the extent of intervention literature in cancer early diagnosis in low- and middle-income countries had not been characterized. This study aimed to outline and characterize interventions across all cancer types and across all countries. This systematic review demonstrated that interventions have been investigated targeting both the general population and health care professionals. Furthermore, this review demonstrates that the majority of studies report knowledge as an outcome measure, rather than clinically significant measures that improve cancer-related outcomes, such as delay intervals or downstaging of disease. Future interventions should address clinically relevant measures to better assess efficacy of interventions.

Effectiveness of An Educational Intervention of Breast Cancer Screening Practices Uptake, Knowledge, and Beliefs among Yemeni Female School Teachers in Klang Valley, Malaysia: A Study Protocol for a Cluster-Randomized Controlled Trial

Breast cancer is the most common cancer spread among women worldwide. Whereas many studies have discussed the significance of breast cancer screening among women in various countries, few have attempted to discuss this topic among female school teachers. As teachers educate and communicate with students, this may play an essential role in health education and in promoting healthy behavior, such as breast cancer screening. The primary goal of this study is to develop and implement an educational intervention of breast cancer screening and evaluate its effectiveness among Yemeni female school teachers in Malaysia. This was carried out as per the health belief model. A cluster-randomized controlled trial was conducted among 183 Yemeni female school teachers in twelve schools in Klang Valley, Malaysia. A random assignment of the target schools was made to include them within the intervention or control group. Participants in the intervention group were offered a 90-min session for one-day educational intervention on breast cancer screening. On the other hand, participants in the control group were offered the same educational materials at the end of the study. Relevant data was collected at baseline, one month following the intervention, and then three- and six-months follow-up assessments. Analysis of such data was done via IBM SPSS software 25.0 by generalized estimating equations (GEE) to assess the differential changes over time. A primary outcome embodied in breast cancer screening practice uptake was expected. Secondary outcomes include the target group’s knowledge on and beliefs of breast cancer screening. This study intends to contribute to the credibility and effectiveness of utilizing a theory-based breast cancer screening intervention in order to raise the awareness of women on conducting breast cancer screening.

The Effect of Counseling on Breast Cancer Awareness in Rural Iranian Women: a Randomized Controlled Clinical Trial

In a community such as Iran where late presentation is predominant and the majority of breast cancer patients are diagnosed at advanced stages of the disease, there is an urgent need for improving the level of awareness about breast cancer and early detection measures. Given that rural residents are at higher risk for late diagnosis of breast cancer because they have less education, income, and access to advanced screening technologies, this study was conducted to determine the effect of counseling on breast cancer awareness of rural Iranian women. This randomized clinical trial was conducted on 60 rural women from the Abish Ahmad area in northwestern Iran in 2017. The randomized cluster method was used for sampling. From 20 rural health houses and centers, about one third were selected randomly. From the six selected clusters, three were randomly allocated as the control group and three as the intervention group. Using convenience sampling, 30 women between the ages of 40 and 69 were selected from the control group and 30 from the intervention group. The intervention group attended six group counseling sessions. Data was gathered using a demographic and obstetrical information questionnaire and breast cancer awareness measures. The chi-square, independent t test and ANCOVA by controlling for the baseline scores were used to analyze the data. After counseling, the mean knowledge about breast cancer score was significantly higher in the intervention group than in the control group (adjusted mean difference, 17.02; confidence interval (CI) 95%, 15.44 to 18.59; p < 0.001). The mean barriers to breast cancer screening score showed a significant decrease in the intervention group compared to the control group (AMD, - 1.74; 95% CI - 3.12 to - 0.36, p < 0.001). After intervention, the frequency of breast self-exam showed a significant difference between groups (p < 0.001); but for confidence about noticing breast changes, no significant difference was observed between groups (p = 0.08). Group counseling had a significant effect on enhancing breast cancer awareness of rural Iranian women, except for confidence about noticing breast changes.

Effect of Health Education on Female Teachers' Knowledge and Practices Regarding Early Breast Cancer Detection and Screening in the Jazan Area: a Quasi-Experimental Study

Educational programs are important tools for breast cancer prevention. The purpose of this study was to assess the effectiveness of health education in improving the knowledge and practices of female teachers regarding screening tools and the early detection of breast cancer. A two-group quasi-experimental design was conducted among 150 female teachers, who were selected from 75 schools of the Jazan General Administration of Education. Schools were chosen by a simple cluster randomization method and non-randomly assigned to either the intervention or control group. Eligible participants were recruited by a simple randomization method, proportional to the total number of teachers at each school. Those in the intervention group (n = 75) were compared to the control group (n = 75) at baseline, as well as at 6 weeks and 3 months post-intervention. Knowledge of breast cancer screening tools was measured using a modified version of the Breast Cancer Knowledge test. Breast self-examination, clinical breast examination, and mammography practices were also measured. Compared to the control group, the intervention group showed a statistically significant increase in knowledge and practice levels at both 6 weeks and 3 months post-intervention. Thus, the results of this study provide evidence that group health education programs are effective in improving breast cancer knowledge and practices in female teachers. Clinical Trial Registration number: NCT03398057 .

Effectiveness of the Theory-Based Educational Interventions on Screening of Breast Cancer in Women: A Systematic Review and Meta-Analysis

Screening plays an essential role in the reduction of mortality and morbidity of breast cancer, which is one of the most common cancers in women worldwide. The aim of this study was to find out whether the use of health education model and theory-based behavioral interventions is effective in women’s breast cancer screening behavior. Applying different search strategies, we searched electronic databases including PubMed, ScienceDirect, Web of Science, and Scopus without time limit from January 12 to March 11, 2017. Keywords included “Breast neoplasm,” Screening,” “Women,” and “Health Education.” First, screening was conducted based on title, abstract, and full text. Then, the studies were screened according to the selection criteria of our study. The relevant and eligible studies were critically appraised by Delphi checklist. In addition, a meta-analysis of eligible studies was conducted with the random-effect approach. Twenty-six of 8,620 initial studies (with sample size of 10,681 in the intervention group and 8,854 in the control group) were included in the final analysis. The results of the meta-analysis showed that the probability of screening behavior in the intervention group is 1.4 times of that in the control group. Furthermore, subgroup analysis by the type of screening behavior indicates that the probabilities of conducting breast self-examination and mammography in the intervention group are 1.9 and 1.4 times of those in the control group. The health education program has a significant impact on breast cancer screening behaviors, particularly breast self-examination. Thus, given the positive effects of the educational screening programs in women, it is suggested that these programs must be continuously pursued with long-term follow-up and increasing rates of screening behaviors should be monitored.

Low Breast Conserving Surgery (BCS) rates in public hospitals in Malaysia: The effect of stage and ethnicity

INTRODUCTION

Breast-conserving surgery (BCS) with radiation therapy is the procedure of choice for early-stage breast cancer. Survival and locoregional recurrence is non-inferior to mastectomy, with superior cosmetic and psycho-social outcomes. Differing health systems have demonstrated a wide variation in the rate of BCS. Little is known about the rate of BCS and factors influencing its practice in middle resource countries. This study aims to examine the BCS rates in Malaysia and to identify factors influencing its uptake.

METHODOLOGY

This is a multi-centre, cross-sectional study involving the University of Malaya Medical Centre (UMMC), Queen Elizabeth II Hospital (QEH), and Tengku Ampuan Rahimah Hospital (TARH). Patients diagnosed with invasive breast cancer from January 2014 to December 2015 were included, excluding stromal cancers and lymphomas. Univariate and multivariate analyses identified factors influencing BCS.

RESULTS

A total of 1005 patients were diagnosed with breast cancer in the allocated time frame. Excluding incomplete records and those who did not have surgery, 730 patients were analysed. Overall BCS rate was 32.9%. The BCS rate was highest at QEH (54.1%), followed by UMMC (29.5%), and TARH (17.4%). 16.9% had BCS after neoadjuvant therapy. Factors influencing BCS uptake included age, ethnic group, breast-surgeon led services, AJCC Stage, tumour size, HER-2 expression, and tumour grade.

CONCLUSIONS

The rate of BCS in Malaysia is low. A wide variation of rate exists among the studied hospitals. Younger age, earlier AJCC stage, and the presence of a Breast sub-specialist surgeon, would make it more likely that the patient has her breast conserved.

Impact of a Breast Cancer Educational Program on Female University Students' Knowledge, Attitudes, and Practices

Breast cancer (BC) is a worldwide fatal cancer among females. Efforts fighting against this disease should start with females at younger ages. This study evaluated the effectiveness a BC educational program in promoting female university students' knowledge and attitudes towards BC and practices of breast self-examination (BSE). A pre- and post-test design was used in two phases; pre- and post-intervention phase. A 1-day educational program was conducted with theoretical and practical educational sessions. Participants were evaluated twice (before and 2 weeks after the intervention) for the following variables: knowledge regarding BC warning signs, BC risk factors and knowledge in regard to BSE, in addition to their attitudes and practices of BSE. A total of 110 participants were randomized into either intervention (n = 64, 58.2%) or control group (n = 46, 41.8%). Analysis revealed that participants in both groups had relatively low level of knowledge, negative attitudes, and poor practice towards BC and BSE before attending the intervention. Analysis of the post test revealed that participants in the interventional group had significant improvement in knowledge, positive attitudes, and more practice of BSE compared to participants in the control group. The implementation of a BC awareness program had positive effects on the female university students' knowledge, attitudes, and practices regarding BC and BSE. Findings from this study strengthen and reinforce the importance of conducting such awareness programs for this young age group.

An Application of the Protection Motivation Theory to Predict Breast Self-Examination Behavior among Female Healthcare Workers

OBJECTIVE

Breast cancer is the most prevalent cancer among women and has the highest mortality rate among the women around the world. Early diagnosis of this cancer increases the survival of the patients. The aim of this study was to determine the predictor factors for breast self-examination (BSE) based on the Protection Motivation Theory (PMT) among female healthcare workers in Hamadan University of Medical Sciences.

MATERIALS AND METHODS

This analytical-descriptive study was conducted on 501 employed women in age range of 20-61 years old in Hamadan University of Medical Sciences in west of Iran during 2018. Participants in the study were random stratified sampling selected. Data collection tools were demographic information and the constructs of PMT. The data were analyzed by descriptive statistics and the logistic regression tests.

RESULTS

The results showed that only 9% of participants performed BSE regularly and monthly. The most important reason for lack of BSE was its triviality. Linear regression analysis showed that the structure of perceived threat appraisal is the predictor of the intention to perform BSE (R2=0.027). Moreover, the logistic regression analysis showed that the protection motivation construct was a strong predictor for BSE (R2=0.25).

CONCLUSION

The frequency of practice of BSE in female healthcare workers is low. Therefore, it is imperative to periodically emphasize the importance of early breast cancer diagnosis for them and the design of educational programs based on the PMT can increase the regular of BSE behavior.

Effects of Health Belief Model-Based Education on Health Beliefs and Breast Self-Examination in Nursing Students

Objective

This study was carried out to investigate the effect of an education program based on the health belief model (HBM) on nursing students' health beliefs and on their practices of breast self-examination (BSE).

Methods

This research was a semi-experimental intervention study with a single group, pretest and posttest design. The sample of the research consisted of 48 students in the 3^rd year of study. Data were collected before the education program and 6 months and 1 year after the training. A sociodemographic information form, the breast cancer knowledge form, the HBM scale, and the BSE proficiency rating instrument were used. Descriptive statistics and repeated measures ANOVA were used to examine the relationships among the variables.

Results

Implementing the educational program was found to be statistically insignificant for the HBM. Knowledge about breast cancer and BSE skills increased after the training. The percentage of students practicing regular BSE was determined as 14.6% before training, 45.8% after 6 months, and 28.1% after 1 year.

Conclusions

The education provided to the students increased their HBM scores, knowledge about breast cancer, and BSE skills. However, the frequency of regular BSE was still quite low after training.

Effects of Model-Based Interventions on Breast Cancer Screening Behavior of Women: a Systematic Review

Background: Breast cancer is a great concern for women’s health; early detection can play a key role in reducing associated morbidity and mortality. The objective of this study was to systematically assess the effectiveness of model-based interventions for breast cancer screening behavior of women. Methods: We searched Scopus, PubMed, Web of Science, Science Direct, Cochrane library and Google scholar search engines for systematic reviews, clinical trials, pre- and post-test or quasi-experimental studies (with limits to publication dates from 2000-2017), Keywords were: breast cancer, screening, systematic review, trials, and health model. In this review, qualitative analysis was used to assess the heterogeneity of data. Results: Thirty six articles with 17,770 female participants were included in this review. The Health belief model was used in twenty three articles as the basis for intervention. Two articles used both the Health belief model and the Health Promotion Model, 5 articles used Health belief model and The Trans theoretical Model, 2 used Hthe ealth belief model and Theory planned behavior, 2 used the Health belief model and the Trans theoretical Model, 2 used the Trans theoretical Model, 1 used social cognitive theory, and 1 used Systematic Comprehensive Health Education and Promotion Model. The results showed that model-based educational interventions are more effective for BSE and CBE and mammography screening behavior of women compare to no model based intervention. The Health belief model was the most popular model for promoting breast cancer screening behavior. Conclusions: Educational model-based interventions promote self-care and create a foundation for improving breast cancer screening behavior of women and increase policy makers’ awareness and efforts towards its enhancement breast cancer screening behavior.

Effects of an Educational Intervention on Breast Self-Examination, Breast Cancer Prevention-Related Knowledge, and Healthy Lifestyles in Scholars from a Low-Income Area in Bogota, Colombia

The aim of this study was to evaluate the effects of an educational intervention on breast self-examination, cancer prevention-related knowledge, practices, and behavior change in scholars from a low-income area in Bogota, Colombia. Uncontrolled trial was conducted in 155 scholars. Two educational sessions, 90 min each, were carried out in March 2015 according to the Colombian guidelines for educational communication in the framework of cancer control. All participants completed a self-reported questionnaire at pre- and post-intervention, as well as 1, 3, and 6 months after the intervention. Breast self-examination was practiced by 78.1% of the scholars, and the overall knowledge of breast cancer risk factors was poor. The educational intervention resulted in significant improvements on breast self-examination practice, the knowledge of the technique, and the knowledge of the main risk factors for breast cancer as well as the practice of physical activity and vegetable intake at 6 months follow-up. An educational intervention according to the Colombian guidelines for educational communication in the framework of cancer control improved the practice of breast self-examination, cancer prevention-related knowledge, as well as the practice of physical activity and vegetable consumption in scholars from a low-income area in Bogota, Colombia. Further randomized controlled studies are warranted.

A Survey on Breast Cancer Awareness Among Medical, Paramedical, and General Population in North India Using Self-Designed Questionnaire: a Prospective Study

Breast cancer (BC) has become the most common cancer in urban women. Unfortunately, most women are not aware of BC symptoms/signs, prevention, and management. In resource-limited countries like India where we do not have structured screening/awareness programs, a majority of women present with locally advanced BC. The aim of our study is to identify the present status of awareness about BC prevention, early detection, symptoms, and management in urban and rural Indian women (medical, paramedical, and nonmedical) and to assess whether education and socioeconomic strata have any role in better awareness about BC or not. We did a prospective cross-sectional observation study among the medical, paramedical, and nonmedical women in the northern part of India. We designed a questionnaire keeping in mind the three domains about BC-knowledge (questions 1-25 include risk factors, genetics, lifestyle changes, hormones, associated cancers, and modes of presentation like lump, nipple/skin changes), breast self-examination (questions 25-37), and attitude to prevention and early detection (questions 38-44). We also asked how many do breast self-examination (BSE) and what they think are the three main factors responsible for late presentation and the three main ways to increase BC awareness. The Likert scale was used for objective assessment. We analyzed the whole data using SPSS software version 15. A total of 220 women out of 270 completed the questionnaire. Out of 220 women, 26.4% were medical, 20.9% paramedical, and 52.7% nonmedical. Most women were educated (82.7%) and married (65%). 59.5% women resided in urban areas and the rest (40.5%) were from rural areas. We found that there was relatively more knowledge in the medical group; however, the skills of BSE and attitude to prevention and early detection in all the three subgroups and among rural and urban women were suboptimal and not different significantly. The three main factors responsible for delayed presentation were shyness and not knowing BSE, ignorance about BC symptoms, and social stigma of cancer along with financial constraints. The three main ways to improve BC awareness suggested were to have more advertisements on television and social media, roadside campaigns and in colleges along with group discussions and debates, and at grassroots level to involve Anganwadi workers and nurses to create more awareness in villages. There was less breast cancer knowledge and awareness among the nonmedical women compared to those among the medical and paramedical, the skills of BSE and attitude to prevention and early detection were suboptimal in all the three groups. Rural or urban dwellings did not make much difference in BC knowledge, skills of BSE, and attitude to prevention. More awareness regarding breast cancer symptoms with early detection and BSE need to be addressed with more information dissemination via social media, campaigns, and involvement of paramedics and social workers.

Testicular Cancer and Testicular Self-Examination; Knowledge, Attitudes and Practice in Final Year Medical Students in Nigeria

The testicular cancer (TCa) incidence is increasing in many countries, with age-standardized incidence rates up to 7.8/100,000 men in the Western world, although reductions in mortality and increasingly high cure rates are being witnessed at the same time. In Africa, where rates are lower, presentation is often late and morbidity and mortality high. Given this scenario, awareness of testicular cancer and practice of testicular self-examination among future first response doctors is very important. This study was conducted to determine knowledge and attitude to testicular cancer, and practice of testicular self-examination (TSE) among final (6th) year medical students. In addition, the effect of an intervention in the form of a single PowerPoint® lecture, lasting 40 minutes with image content on testicular cancer and testicular self examination was assessed. Pre and post intervention administration of a self-administered structured pre tested questionnaire was performed on 151 medical students, 101 of whom returned answers (response rate of 66.8%). In the TC domain, there was a high level of awareness of testicular cancer, but poor knowledge of the age group most affected, with significant improvement post intervention (p<0.001). Notable also was the poor awareness of the potential curability of TC, this also being improved following the intervention (p<0.001). A poor level of awareness and practice of testicular self-examination pre-intervention was found considering the nature of the study group. Respondents had surprisingly weak/poor responses to the question “How important to men’s health is regular testicular self-examination?” Answers to the questions “Do you think it is worthwhile to examine your testis regularly?” and “Would you be interested in more information on testicular cancer and testicular self-examination?” were also suboptimal, but improved post intervention p<0.001, p<0.001 and p=0.037. Age, gender and marital status were without specific influence. In conclusion, this study showed poor levels of knowledge regarding epidemiology of TCa and its potential curability when detected early. There was also a poor awareness of, practice of, and poor attitudes to TSE. The significant improvement in these parameters post intervention indicates value in educational intervention. We recommend inclusion of TCa coverage and TSE teaching in the secondary school curriculum (targeting adolescents). Greater emphasis should also be given to testicular cancer in the curricula of medical schools and other training institutions for health care personnel.