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Briggs ES, Thomas RM, Frost MC, Fletcher OV, Crothers K, Chalal CK, Shahrir SF, McClure JB, Catz SL, Williams EC. "I Thought Cancer was a Tobacco Issue": Perspectives of Veterans with and without HIV on Cancer and Other Health Risks Associated with Alcohol and Tobacco/Nicotine Use. AIDS Behav 2024:10.1007/s10461-024-04363-6. [PMID: 38869757 DOI: 10.1007/s10461-024-04363-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/14/2024]
Abstract
U.S. Veterans and people living with HIV (PWH) experience higher rates of unhealthy alcohol and tobacco/nicotine use than non-Veterans and people without HIV (PWoH). Both groups are susceptible to adverse health outcomes associated with alcohol and tobacco/nicotine use. We explored awareness of alcohol- and tobacco/nicotine-related cancer and immune health risks among Veterans Health Administration (VA) patients with and without HIV. Among a sample of 41 (46% PWH; 73% male; 39% Black) purposively-selected VA patients receiving care 2020-2021 we conducted semi-structured interviews via telephone; interviews were recorded, transcribed and analyzed using a Rapid Assessment Process. Purposive selection was based on HIV status, alcohol and/or tobacco/nicotine use, and demographics. Among participants, 66% reported current smoking, and most screened positive for unhealthy alcohol use. Participants had high awareness of cancer and other health risks related to smoking but low awareness of synergistic risks and cancer risks associated with alcohol use despite awareness of a range of other alcohol-related risks. Awareness of alcohol and/or tobacco/nicotine's impacts on the immune system was variable. Findings did not distinctly differ between PWH and PWoH. Low awareness of alcohol-related cancer risk, risks of co-occurring use, and varying awareness of the impacts of alcohol and tobacco/nicotine on the immune system suggest a need for improved messaging regarding substance use-related cancer and immune risk. This may be especially important among PWH, for whom the prevalence and adverse effects of alcohol and tobacco use, and immune dysfunction are higher.
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Affiliation(s)
- Elsa S Briggs
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 3980 15th Ave NE, Seattle, WA, 98105, USA.
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA.
| | - Rachel M Thomas
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 3980 15th Ave NE, Seattle, WA, 98105, USA
| | - Madeline C Frost
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 3980 15th Ave NE, Seattle, WA, 98105, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Olivia V Fletcher
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 3980 15th Ave NE, Seattle, WA, 98105, USA
| | - Kristina Crothers
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 3980 15th Ave NE, Seattle, WA, 98105, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Clementine K Chalal
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 3980 15th Ave NE, Seattle, WA, 98105, USA
| | - Shahida F Shahrir
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 3980 15th Ave NE, Seattle, WA, 98105, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Center for Health Workforce Studies, Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Jennifer B McClure
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Sheryl L Catz
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA
| | - Emily C Williams
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 3980 15th Ave NE, Seattle, WA, 98105, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
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Nakisige C, de Fouw M, Nakalembe M, Orem J, Atukonyera D, Musheshe M, Koot J, de Zeeuw J, Beltman J, Stekelenburg J. Baseline knowledge on risk factors, symptoms and intended behavior of women and men towards screening and treatment of cervical cancer in rural Uganda: a cross-sectional study. BMC Cancer 2024; 24:450. [PMID: 38605317 PMCID: PMC11008004 DOI: 10.1186/s12885-024-12223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/02/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Knowledge of risk factors and symptoms of cervical cancer has been found to promote uptake of screening of cervical cancer. Most interventions targeted women without much involvement of men (husbands/decision makers) who are often decision makers in many low- and middle-income countries. This study aimed at assessing baseline knowledge and intended behavior of both women and men to enable design specific targeted messages to increase uptake of cervical cancer screening and promote early detection of women with symptoms. METHODS This cross-sectional study was conducted in two districts in Western Uganda using the modified African Women Awareness of CANcer (AWACAN) questionnaire. Women aged 30-49 years and their husbands/decision makers were interviewed. Knowledge on risk factors and symptoms, intended behavior and barriers towards participation in cervical cancer screening and treatment were assessed. Descriptive and logistic regression analyses were done to establish the association between knowledge levels and other factors comparing women to men. RESULTS A total of 724 women and 692 men were enrolled. Of these, 71.0% women and 67.2% men had ever heard of cervical cancer and 8.8% women had ever been screened. Knowledge of risk factors and symptoms of cervical cancer was high and similar for both women and men. Lack of decision making by women was associated with low knowledge of risk factors (X2 = 14.542; p = 0.01), low education (X2 = 36.05, p < 0.01) and older age (X2 = 17.33, p < 0.01). Men had better help seeking behavior than women (X2 = 64.96, p < 0.01, OR = 0.39, 95% CI: 0.31-0.50) and were more confident and skilled in recognising a sign or symptom of cervical cancer (X2 = 27.28, p < 0.01, OR = 0.52, CI (0.40-0.67). CONCLUSION The baseline knowledge for cervical cancer was high in majority of participants and similar in both women and men. Their intended behavior towards screening was also positive but screening uptake was very low. This study suggests developing messages on multiple interventions to promote screening behavior in addition to education, consisting of male involvement, women empowerment and making services available, accessible and women friendly.
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Affiliation(s)
- Carolyn Nakisige
- Department of Gynaecologic-Oncology, Uganda Cancer Institute, Kampala, Uganda.
| | - Marlieke de Fouw
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Jackson Orem
- Department of Gynaecologic-Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Dan Atukonyera
- Uganda Rural Development Training Program, Kagadi, Uganda
| | | | - Jaap Koot
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janine de Zeeuw
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jogchum Beltman
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Obstetrics and Gynecology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Lamichhane B, Adhikari B, Poudel L, Pandey AR, Kakchhapati S, K. C. SP, Giri S, Dulal BP, Joshi D, Gautam G, Baral SC. Factors associated with uptake of breast and cervical cancer screening among Nepalese women: Evidence from Nepal Demographic and Health Survey 2022. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002971. [PMID: 38466682 PMCID: PMC10927089 DOI: 10.1371/journal.pgph.0002971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024]
Abstract
Breast cancer screening (BCS) and cervical cancer screening (CCS) are integral parts of initiatives to reduce the burden associated with these diseases. In this context, we aimed to determine factors associated with BCS and CCS uptake among Nepalese women aged 30 to 49 years using data from the Nepal Demographic Health Survey (NDHS) 2022. We performed a weighted analysis to account complex survey design of the NDHS 2022. We employed univariable and multivariable logistic regression to determine factors associated with the uptake of BCS and CCS and results were presented as crude odds ratio and adjusted odds ratio (AOR) along with 95% confidence interval (CI). The uptake of BCS and CCS among Nepalese women aged 30 to 49 years were 6.5% and 11.4% respectively. Women from Terai compared to mountain region (AOR = 0.54, 95%CI: 0.31, 0.93) and those engaged in agriculture compared to non-working (AOR = 0.59, 95%CI: 0.42, 0.82) women had lower odds of BCS uptake. Conversely, Dalit women compared to Brahmin/Chhetri (AOR = 2.08, 95%CI: 1.37, 3.16), and women with basic (AOR = 1.49, 95%CI: 1.04, 2.13), secondary (AOR = 1.96, 95%CI: 1.33, 2.88), and higher education (AOR = 2.80, 95% CI: 1.51, 5.19) compared to those with no education had higher odds of BCS uptake. Women from rural areas (AOR = 0.76, 95%CI: 0.61, 0.96), and those living in Bagmati (AOR = 2.16, 95% CI: 1.44, 3.23) and Gandaki (AOR = 2.09, 95%CI: 1.40, 3.14) provinces had higher odds of CCS uptake compared to their urban counterparts and those living in Koshi province, respectively. The odds of CCS increased with age (AOR = 1.06, 95%CI: 1.04, 1.08). Women with secondary education (AOR = 1.47, 95%CI: 1.06, 2.04) had higher odds of CCS uptake compared to those without education. Similarly, married women (AOR = 8.24, 95%CI: 1.03, 66.21), and those with health insurance (AOR = 1.41, 95%CI: 1.08, 1.83) had higher odds of CCS. In conclusion, the uptake of both BCS and CCS was relatively poor among Nepalese women indicating a need for targeted and tailored intervention to increase BCS and CCS uptake.
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Affiliation(s)
- Bipul Lamichhane
- Research and Development Department, HERD International, Lalitpur, Nepal
| | - Bikram Adhikari
- Research and Development Department, HERD International, Lalitpur, Nepal
| | - Lisasha Poudel
- Central Department of Public Health Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Achyut Raj Pandey
- Research and Development Department, HERD International, Lalitpur, Nepal
| | | | | | - Santosh Giri
- Research and Development Department, HERD International, Lalitpur, Nepal
| | | | - Deepak Joshi
- Research and Development Department, HERD International, Lalitpur, Nepal
| | - Ghanshyam Gautam
- Research and Development Department, HERD International, Lalitpur, Nepal
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Christensen AJ, Mwayi J, Mbabazi J, Juncker M, Kallestrup P, Kraef C. Fighting cervical cancer in Africa: a cross-sectional study on prevalence and risk factors for precancerous lesions in rural Uganda. Public Health 2023; 225:87-95. [PMID: 37922591 DOI: 10.1016/j.puhe.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/06/2023] [Accepted: 09/26/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To identify risk factors for precancerous cervical lesions and factors associated with treatment delay among women in the rural Busoga Region, Uganda. STUDY DESIGN A retrospective cross-sectional study from a regional cervical cancer screening program and from cervical cancer patients enrolled in a region-wide palliative care program. METHODS Logistic regression analysis was conducted to assess risk factors for screening positive for precancerous lesions. In a separate analysis, factors associated with treatment delay were assessed among women enrolled in the palliative care program. RESULTS Three thousand nine hundred forty-six women were included from the screening program and 334 from the palliative care program. In total, 7.6% of screening participants had precancerous lesions. Within Busoga Region, the highest positivity rate was found in Bugweri and Namayingo Districts. Abnormal vaginal bleeding (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI] 1.15-2.21; p = 0.005) and older age at first menstrual period (aOR 1.08; 95% CI 1.01-1.16; p = 0.03) were associated with having a precancerous lesion. Among palliative care patients, a history of previous contact with the health care system was associated with a delay in enrolment (≥12 months from first symptom presentation until commencement in palliative care; aOR 5.23; 95% CI 1.16-36.54; p = 0.047). CONCLUSIONS The results underline an unmet need for broad-scale cervical cancer screening focusing on all women in the reproductive age. Abnormal bleeding was the only substantial risk factor for precancerous lesions, indicating that specific algorithms to identify high-risk populations may not be applicable in this population. Increased awareness, resources, and funding are still necessary to achieve global cervical cancer elimination.
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Affiliation(s)
| | - J Mwayi
- Rays of Hope Hospice Jinja, Uganda
| | | | | | - P Kallestrup
- Department of Public Health, Aarhus University, Denmark; Danish Non-Communicable-Disease Alliance, Denmark
| | - C Kraef
- Department of Infectious Diseases, Rigshospitalet Copenhagen, Denmark; Heidelberg Institute of Global Health, University of Heidelberg, Germany; Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital - Rigshospitalet, Denmark
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Ssemata AS, Muhumuza R, Seeley J, Lombe DC, Mwamba M, Msadabwe S, Mwaka AD, Aggarwal A. Moving forward through consensus: a national Delphi approach to determine the top research priorities in prostate cancer in Uganda. BMJ Open 2023; 13:e075739. [PMID: 38035740 PMCID: PMC10689405 DOI: 10.1136/bmjopen-2023-075739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVE To identify key areas for research in prostate cancer (PC) in the Ugandan context by establishing the major health system, socioeconomic and clinical barriers to seeking, reaching and receiving high-quality cancer care. DESIGN Modified Delphi Technique. SETTING Government and private-not-for-profit hospitals. METHODS We applied a two-stage modified Delphi technique to identify the consensus view across cancer experts. In round 1, experts received a questionnaire containing 21 statements drawn from a systematic review identifying the reason for the delay in accessing cancer care. Each statement was scored out of 20. Statements scoring ≥15 from over 70% of participants were prioritised for inclusion while statements for which <30% of participants gave a score of ≥15 were excluded. Sixteen statements were included in round 2 as they did not receive consensus for inclusion or exclusion. RESULTS We found that the top six research priority areas arise from challenges including: (1) lack of diagnostic services-ultrasound, laboratory tests and biopsy facilities; (2) high costs of services, for example, surgery, radiotherapy, hormone therapy are unaffordable to most patients, (3) lack of essential medicines, (4) limited radiotherapy capacity, (5) lack of awareness of cancer as a disease and low recognition of symptoms, (6) low healthcare literacy. The lack of critical surgical supplies, high diagnostic and treatment costs were ranked highest in order of importance in round 1. Round 2 also revealed lack of diagnostic services, unavailability of critical medicines, lack of radiotherapy options, high costs of treatments and lack of critical surgical supplies as the top priorities. CONCLUSION These research priority areas ought to be addressed in future research to improve prompt PC diagnosis and care in Uganda. There is need to improve the supply of high-quality affordable anticancer medicines for PC patients so as to improve the survivorship from the cancer.
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Affiliation(s)
- Andrew Sentoogo Ssemata
- Social Aspects of Health Across the Lifecourse, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard Muhumuza
- Social Aspects of Health Across the Lifecourse, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | - Janet Seeley
- Social Aspects of Health Across the Lifecourse, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Amos Deogratius Mwaka
- Department of Internal Medicine, Mulago Hospital/Makerere University, Kampala, Uganda
- Department of Medicine, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Ajay Aggarwal
- Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London, UK
- King's College London, London, UK
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Rafat Munir Lawis M, Sabir M. Breast cancer awareness among Sudanese females in Omdurman city: 2021. BMC Public Health 2023; 23:1907. [PMID: 37789363 PMCID: PMC10546643 DOI: 10.1186/s12889-023-16833-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/25/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Breast cancer is the most commonly diagnosed malignancy among women worldwide. In contrast to Europe, it presents generally very late in Africa. As with the rest of Africa, it is the most common primary malignancy of females in Sudan, and generally presents in stage III or IV disease. This study is intended to analyse the level of breast cancer awareness among women of Sudan. OBJECTIVE To assess the level of awareness of breast cancer among Sudanese females, and their attitude towards breast changes. Also, to establish possible associations between several variables: (education level, age, contact with a breast cancer patient, residence) on awareness. METHODOLOGY A descriptive cross-sectional community-based study of 385 females in Omdurman city, selected by convenience sampling. An interview based Arabic version of Breast Cancer Awareness Measure (BCAM) was used. Data was coded and analysed using Statistical Package for Social Sciences (SPSS) v.20. RESULTS A total of 385 females were included, of which 38.7% were 20-30 years, 47.8% were single, 53.8% had university education, 41% of them were currently unemployed, and 54.3% resided in Ummbadda's locality. When asked about the signs and risk factors of breast cancer, 55.06% and 55.8% failed to name any. The cumulative percentage of correct answers of close-ended question about signs, risk factors and Federal Ministry of Health (FMoH) screening program were 42.8%, 30.7% and 44.7% in that order. Only 38.2% knew the right method BSE, 48.2% of them rarely practiced it. 38.2% noticed a change in the breast tissue but didn't visit a doctor. The majority of them, though, said they would see a doctor if they noticed a change in the future. CONCLUSION There is a severe lack of awareness of breast cancer among females of the Sudanese society. Also, there was a clear ignorant attitude practiced by a significant proportion of the candidates. RECOMMENDATIONS Further research, to address the limitations of this study is to be done. FMoH has to improve its media massage and arrange targeted awareness campaigns.
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Affiliation(s)
| | - Mustafa Sabir
- AlNeelain University Faculty of medicine, Khartoum, Sudan
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Bolarinwa OA, Holt N. Barriers to breast and cervical cancer screening uptake among Black, Asian, and Minority Ethnic women in the United Kingdom: evidence from a mixed-methods systematic review. BMC Health Serv Res 2023; 23:390. [PMID: 37087506 PMCID: PMC10122823 DOI: 10.1186/s12913-023-09410-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/17/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Cancer is currently the leading cause of mortality globally, with new cancer cases estimated at 19.3 million and almost 10 million deaths in 2020. Specifically, breast and cervical cancer incidence and mortality prevalence among women of the minority group or marginalised populations in Europe have continued to be a public health concern due to the low uptake of cancer screening. Thus, this study utilised a mixed-method systematic review to identify barriers to breast and cervical screening uptake among Black, Asian, and Minority Ethnic women in the United Kingdom. METHODS Databases including PubMed, CINAHL, British Nursing Index, Web of Science, EMBASE, and Scopus databases, were systematically searched for studies on barriers to breast and cervical screening uptake among Black, Asian, and Minority Ethnic women in the United Kingdom published in English between January 2010 to July 2022. This mixed-method systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in reporting the included studies' results. The cluster mapping approach was used to identify and classify the barriers into themes. RESULTS Thirteen eligible studies were included in this current review. Seven of the thirteen studies used quantitative cross-sectional research design, while six used qualitative cross-sectional research design. These studies were conducted across the United Kingdom. Five themes were developed from the cluster mapping, and thirty-four sub-theme barriers to the uptake of breast and cervical cancer screening among Black, Asian, and Minority Ethnic women in the United Kingdom were identified. The developed themes in relation to the barriers include; socio-demographic characteristics, health service delivery, cultural, religious & language, the gap in knowledge & awareness, and emotional, sexual & family support. CONCLUSION The study concluded that barriers in socio-demographic characteristics, health service delivery, cultural, religious and language, the gap in knowledge & awareness, and emotional, sexual & family support were identified as non-uptake of breast and cervical cancer screening among Black, Asian, and Minority Ethnic women in the United Kingdom. Reducing or eliminating these barriers would improve the benefits of timely breast and cervical cancer screening in the United Kingdom.
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Affiliation(s)
- Obasanjo Afolabi Bolarinwa
- Department of Public Health & Well-Being, Faculty of Health & Social Care, University of Chester, Chester, UK.
- Institute for Advanced Studies in the Humanities, University of Edinburgh, Edinburgh, UK.
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
- Department of Allied and Public Health, Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, Canterbury, UK.
| | - Nicole Holt
- Department of Allied and Public Health, Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, Canterbury, UK
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Afaya A, Japiong M, Konlan KD, Salia SM. Factors associated with awareness of breast cancer among women of reproductive age in Lesotho: a national population-based cross-sectional survey. BMC Public Health 2023; 23:621. [PMID: 37004021 PMCID: PMC10067163 DOI: 10.1186/s12889-023-15443-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Breast cancer is a leading cause of cancer mortality and a major public health problem. The growing number of breast cancer-related deaths has been largely attributed to a lack of awareness of the disease among women. Whilst there have been frequent campaigns promoting breast cancer awareness, evidence suggests that women still lack awareness. Therefore, this study assessed the prevalence and factors associated with the awareness of breast cancer among women of reproductive age in Lesotho. METHODS We used population-based cross-sectional data from the 2014 Lesotho Demographic and Health survey. A total of 6,620 women of reproductive age were included in the analysis. The outcome variable was awareness of breast cancer. Women who heard about breast cancer were considered to be aware of the disease. Multilevel binary logistic regression models were fitted to determine the factors associated with breast cancer awareness among women. RESULTS The level of awareness of breast cancer was 86.8% (95% CI: 85.5, 87.9). Women aged 45-49 years [adjusted odds ratio (AOR) = 2.87, 95% confidence interval (CI): 1.83, 4.48], married women [AOR = 1.51 (95% CI: 1.19, 1.93)], and women with higher educational level [AOR = 12.56, (95% CI: 4.35, 36.28)] were more likely to be aware of breast cancer. Additionally, women who listened to the radio at least once a week [AOR = 1.96, (95% CI: 1.63, 2.37)], those who read newspapers or magazines [AOR = 1.91 (95% CI: 1.48, 2.46)] and women in the wealthiest group [AOR = 2.55, (95% CI: 1.67, 3.89)] had higher odds of breast cancer awareness. However, women who were in rural areas were less likely [AOR = 0.63, (95% CI: 0.47, 0.84)] to be aware of breast cancer than those in urban areas. CONCLUSION The level of awareness of breast cancer among women of reproductive age in Lesotho was extremely low. We recommend that policymakers, clinicians, and public health practitioners should consider the factors identified in this study when designing and developing intervention programs to improve the awareness of breast cancer among women in Lesotho.
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Affiliation(s)
- Agani Afaya
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, South Korea
- Department of Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
| | - Milipaak Japiong
- Department of Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
- School of Nursing, Faculty of Graduate Studies, York University, York, Canada
| | - Kennedy Diema Konlan
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, South Korea
- Department of Public Health, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
| | - Solomon Mohammed Salia
- Department of Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana.
- Graduate School of Medical Sciences, Research Institute SHARE, University of Groningen, Groningen, Netherlands.
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Wang YJ, Wang F, Yu LX, Xiang YJ, Zhou F, Huang SY, Zheng C, Fu QY, Li L, Gao DZ, Zhang Q, Ma ZB, Yu ZG, Liu LY. Worldwide review with meta-analysis of women's awareness about breast cancer. PATIENT EDUCATION AND COUNSELING 2022; 105:1818-1827. [PMID: 34952749 DOI: 10.1016/j.pec.2021.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 12/11/2021] [Accepted: 12/16/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To summarize the awareness levels of breast cancer (BC) worldwide and investigate factors associated with BC awareness to determine differences in awareness between China and other countries. METHODS This systematic review followed the PRISMA guidelines and included 92 articles up to July, 2021. We calculated percentages for BC awareness levels and conducted subgroup analysis and cumulative meta-analysis. RESULTS A total 84% (95% confidence interval [95%CI]: 78-90%) of women knew about BC; however, only 51% (95%CI: 37-66%) and 40% (95%CI: 24-56%) of women were aware of BC symptoms and BC risk factors, respectively. The most commonly known BC symptom was breast lump (71%, 95%CI: 62-80%), and BC family history was the most well-known BC risk factor (61%, 95%CI: 54-69%). Subgroup analysis showed lower awareness levels among Chinese and Asian women than women from other countries. Cumulative meta-analysis showed no obvious progress in BC awareness levels over time. We investigated 15 awareness-related factors, the most frequent of which were education level (61.8%), occupation (29.4%), and age (26.5%). CONCLUSION BC awareness levels remain low. Improving BC awareness is critical, especially in developing countries. PRACTICE IMPLICATIONS Effective education programs are urgently needed to improve women's BC awareness.
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Affiliation(s)
- Yong-Jiu Wang
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Fei Wang
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Li-Xiang Yu
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Yu-Juan Xiang
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Fei Zhou
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Shu-Ya Huang
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Chao Zheng
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Qin-Ye Fu
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Liang Li
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - De-Zong Gao
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Qiang Zhang
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Zhong-Bing Ma
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Zhi-Gang Yu
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China
| | - Li-Yuan Liu
- Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Institute of Translational Medicine of Breast Disease Prevention and Treatment, Shandong University, Jinan, Shandong, China.
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10
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Rendle KA, Ramogola-Masire D, Monare B, Ogden SN, Toneff HK, Saia CA, Wainwright JV, Friebel-Klingner TM, Bazzett-Matabele L, Bhatia R, Bonner N, Ralefala TB, Vuylsteke P, Luckett R, Grover S. Patient perspectives on delays in cervical cancer screening and follow-up care in Botswana: a mixed methods study. BMC Womens Health 2022; 22:195. [PMID: 35643491 PMCID: PMC9148477 DOI: 10.1186/s12905-022-01777-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Delays in screening and timely diagnosis contribute significantly to global disparities in cervical cancer mortality in Botswana and other low- and middle-income countries, particularly those with high rates of HIV. Little is known about the modifiable factors shaping these delays from the perspectives of women themselves and how these perspectives may differ between those living with and without HIV. Methods From March–May 2019, we conducted a concurrent, mixed methods study of women receiving treatment for cervical cancer at a multidisciplinary oncology clinic in Botswana. Enrolled participants completed a one-time, concurrent semi-structured interview and structured questionnaire assessing patient characteristics, screening and HIV-related beliefs and knowledge, and barriers and facilitators to screening and follow-up care. Qualitative data were analyzed using directed content analysis guided by the Model of Pathways to Treatment and triangulated with quantitative questionnaire data to identify areas of convergence and divergence. Fisher’s exact tests were used to explore associations between questionnaire data (e.g., screening knowledge) and HIV status. Results Forty-two women enrolled in the study, 64% of whom were living with HIV and 26% were diagnosed with stage III cervical cancer. Median age was 45 years (IQR 54–67) in those living with HIV and 64 years (IQR 42–53) in those living without. Overall screening rates before symptomatic disease were low (24%). Median time from most proximal screen to diagnosis was 52 median days (IQR 15–176), with no significant differences by HIV status. General screening knowledge was higher among those living with HIV versus those without (100% vs 73%; p < 0.05), but knowledge about HPV and other risk factors was low in both groups. Similar to questionnaire results, qualitative results indicate limited awareness of the need to be screened prior to symptoms as a central barrier to timely screening. Some participants also noted that delays in the receipt of screening results and fear also contributed to treatment delays. However, many participants also described myriad sources of social and tangible support that helped them to overcome some of these challenges. Conclusion Interventions focused on increasing routine screening and supporting timely awareness and access to care are needed to reduce global disparities in cervical cancer.
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Affiliation(s)
- Katharine A Rendle
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology and Office of Research and Graduate Studies, University of Botswana, Gaborone, Botswana
| | - Barati Monare
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Shannon N Ogden
- Department of Health Law, Policy, and Management, Boston University, Boston, MA, USA
| | - Hannah K Toneff
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Chelsea A Saia
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Jocelyn V Wainwright
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Tara M Friebel-Klingner
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Rohini Bhatia
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Tlotlo B Ralefala
- Department of Oncology, Princess Marina Hospital, Gaborone, Botswana
| | - Peter Vuylsteke
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Rebecca Luckett
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
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11
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Moodley J, Harries J, Scott SE, Mwaka AD, Saji S, Walter FM. Exploring primary care level provider interpretation and management of potential breast and cervical cancer signs and symptoms in South Africa. Ecancermedicalscience 2021; 15:1298. [PMID: 34824621 PMCID: PMC8580586 DOI: 10.3332/ecancer.2021.1298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Indexed: 12/24/2022] Open
Abstract
Objectives Women with potential breast and cervical cancer symptoms in South Africa (SA) usually self-present to primary health care (PHC) clinics. The aim of this study was to explore PHC provider interpretation and management of potential breast and cervical cancer signs and symptoms. Methods In-depth interviews with PHC providers incorporating vignettes were conducted between April and May 2019 in two sites in SA. Four vignettes (two breast and two cervical) were developed by the research team to capture aspects of provider symptom interpretation, reasoning, actions and challenges. The content of the vignettes was informed by a preceding community-based survey and qualitative interviews with symptomatic women. Interviews were audio recorded, transcribed verbatim and analysed using a thematic analysis approach. Results Twenty-four PHC providers were interviewed (12 urban, 12 rural; median age: 43 years). Four main themes relating to clinical assessment and reasoning; referral and feedback challenges; awareness of breast and cervical cancer policy guidelines and training and education needs emerged. Vignette-prompted questions relating to presenting symptoms, and possible accompanying symptoms and signs, demonstrated comprehensive proposed history taking and clinical assessment by PHC providers. Cancer was considered as a potential diagnosis by the majority of PHC providers. PHC providers also considered the possibility of infectious causes for both breast and cervical vignettes indicating they would ask questions around human immunodeficiency virus status, use of anti-retroviral therapy, and, for those with cervical symptoms, would need to rule out a sexually transmitted infection. Sexual assault was considered in assessing the cervical symptom scenarios. Providers raised issues around cumbersome booking systems and lack of feedback from referral centres. The need for provider and patient education and training to improve timely diagnosis of breast and cervical cancer was raised. Most providers were not aware of current breast or cervical cancer policy guidelines. Conclusion Clinical assessment at PHC level is complex and influenced by local health issues. Providing context-relevant training and support for PHC providers, and improving referral and feedback systems, could assist timely diagnosis of women with symptomatic breast and cervical cancer.
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Affiliation(s)
- Jennifer Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa.,Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa.,South African Medical Research Council Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa.,https://orcid.org/0000-0002-9398-5202
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa.,https://orcid.org/0000-0001-7359-8419
| | - Suzanne Emilie Scott
- Centre for Oral, Clinical and Translational Sciences, Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, London SE1 9RT, UK.,https://orcid.org/0000-0001-5536-9612
| | - Amos Deogratius Mwaka
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Upper Mulago Jill Road, PO Box 7072, Kampala 256, Uganda.,https://orcid.org/0000-0001-7952-2327
| | - Smiji Saji
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK.,https://orcid.org/0000-0003-0002-6326
| | - Fiona Mary Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK.,Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK.,https://orcid.org/0000-0002-7191-6476
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12
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Moodley J, Constant D, Mwaka AD, Scott SE, Walter FM. Anticipated help seeking behaviour and barriers to seeking care for possible breast and cervical cancer symptoms in Uganda and South Africa. Ecancermedicalscience 2021; 15:1171. [PMID: 33680085 PMCID: PMC7929770 DOI: 10.3332/ecancer.2021.1171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Indexed: 12/23/2022] Open
Abstract
Objectives Breast and cervical cancers are leading causes of cancer morbidity and mortality in sub-Saharan Africa. Most women present with advanced-stage disease and have poor outcomes. This study aimed to describe anticipated help-seeking behaviour for possible breast and cervical cancer symptoms, barriers to accessing health care and factors associated with less timely anticipated help-seeking in urban and rural settings in Uganda and South Africa (SA). Methods We conducted a cross-sectional community-based survey between August and December 2018. Data were collected from one randomly selected woman per household using the African Women Awareness of CANcer breast and cervical cancer tool. Anticipated help-seeking behaviour was dichotomised into waiting <1week or ≥1 week to seek care. Multivariable analysis identified factors associated with anticipated help-seeking behaviour. Results One thousand, seven hundred fifty-eight women participated (Uganda 873, SA 885, median age 34, interquartile ranges 26-47). Most would discuss symptoms with someone close to them (87.7% for breast, 83.0% for cervical symptoms). The majority anticipated seeking care from a health facility in <1 week: 86.1% and 88.0%, respectively, for breast and cervical symptoms. 38.7% of women expected to encounter at least 1 barrier when seeking care. Lack of money for transport or clinic costs was the most common barrier (24.6% of participants). For both cancers and in both countries, women who reported more barriers were significantly less likely to anticipate seeking timely care. In SA, rural location was also associated with longer anticipated time to seek care, adjusted prevalence ratio (aPR) 2.92, 95% confidence interval (CI) 1.48-5.76 and aPR 2.42, 95% CI 1.08-5.45 for breast and cervical cancer, respectively. Conclusion Interventions that improve community level cancer knowledge and highlight the importance of prompt help-seeking for possible symptoms are important to promote timely care seeking. In addition, addressing financial barriers by reducing transport and clinic costs and tackling geographical inequities in access to care could support women in seeking timely care for possible symptoms.
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Affiliation(s)
- Jennifer Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,South African Medical Research Council Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,https://orcid.org/0000-0002-9398-5202
| | - Deborah Constant
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,https://orcid.org/0000-0002-7176-9963
| | - Amos Deogratius Mwaka
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Upper Mulago Jill Road PO Box 7072, Kampala, +256, Uganda.,https://orcid.org/0000-0001-7952-2327
| | - Suzanne Emilie Scott
- Centre for Oral, Clinical and Translational Sciences, Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, SE1 9RT, UK.,https://orcid.org/0000-0001-5536-9612
| | - Fiona Mary Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, CB1 8RN, UK.,https://orcid.org/0000-0002-7191-6476
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13
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Mwaka AD, Walter FM, Scott S, Harries J, Wabinga H, Moodley J. Symptom appraisal, help-seeking and perceived barriers to healthcare seeking in Uganda: an exploratory study among women with potential symptoms of breast and cervical cancer. BMJ Open 2021; 11:e041365. [PMID: 33550241 PMCID: PMC7925866 DOI: 10.1136/bmjopen-2020-041365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/30/2020] [Accepted: 01/19/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE We assessed the process of recognising abnormal bodily changes, interpretations and attributions, and help-seeking behaviour among community-based Ugandan women with possible symptoms of breast and cervical cancer, in order to inform health interventions aiming to promote timely detection and diagnosis of cancer. DESIGN Qualitative in-depth interviews. SETTING Rural and urban communities in Uganda. PARTICIPANTS Women who participated in the African Women Awareness of CANcer cross-sectional survey who disclosed potential breast and cervical cancer symptoms were eligible; recruitment was purposive. Interviews were conducted in women's homes, lasted between 40 and 90 min, were audio-recorded, transcribed verbatim and translated to English. Thematic analysis was used to identify themes and subthemes, underpinned by the conceptual framework of the Model of Pathways to Treatment. RESULTS 23 women were interviewed: 10 had potential symptoms of breast cancer and 13 of cervical cancer. Themes regarding symptom appraisal and help-seeking included the: (1) detection and interpretation of abnormal bodily sensations; (2) lay consultations regarding bodily changes; (3) iterative process of inferring and attributing illnesses to the bodily changes; (4) restricted disclosure of symptoms to lay people due to concerns about privacy and fear of stigmatisation; (5) help-seeking from multiple sources including both traditional and biomedical health practitioners, and (6) multiple perceived barriers to help-seeking including long waiting times, lack of medicines, absenteeism of healthcare professionals, and lack of money for transport and medical bills. CONCLUSION Women with potential symptoms of breast and cervical cancer undergo complex processes of symptom interpretation, attributing symptoms or inferring illness, and lay consultations before undertaking help-seeking and management. Increasing community understanding of breast and cervical cancer symptoms, and tackling perceived barriers to health-seeking, could lead to prompt and appropriate symptom appraisal and help-seeking, and contribute to improving cancer outcomes.
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Affiliation(s)
- Amos Deogratius Mwaka
- Department of Medicine, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, Cambridge University, Cambridge, UK
- University of Melbourne, Centre for Cancer Research, Faculty of Medicine, Dentistry & Health Sciences, Melbourne, Victoria, Australia
| | - Suzanne Scott
- Centre for Oral, Clinical and TranslationalSciences, Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, London, UK
| | - Jane Harries
- Women's Health Research Unit, University of Cape Town School of Public Health & Family Medicine, Faculty of Health Sciences, Cape Town, South Africa
| | - Henry Wabinga
- Department of Medicine, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Jennifer Moodley
- Women's Health Research Unit, University of Cape Town School of Public Health & Family Medicine, Faculty of Health Sciences, Cape Town, South Africa
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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