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SOCIAL FACTORS AFFECTING THE ACCEPTANCE OF BREAST CANCER SCREENING
Background of the Study
Cancer is the leading cause of death in economically developed countries and the second
leading cause of death in developing countries. Breast cancer is by far the most frequent
cancer among women with an estimated 1.38 million new cases diagnosed in 2008 (23%
of all cancers) and ranks second overall (10.9%, of all cancer). It is now the most
common cancer both in developed and developing countries with around 690,000 new
cases estimated in each region (Global Cancer Statistics, 2011).
In high income countries, remarkable progress has been made in cancer management and
care and although cancer incidence continues to rise due to influence of ageing lifestyle
and population growth, mortality has fallen. (Centre for Disease Control-CDC Report
2010) Breast cancer ranks as the fifth cause of death from cancer overall (458,000
deaths), but it is still the most frequent cause of cancer death in women both in
developing and developed region (Global cancer statistics, 2011).
This decrease in mortality and rise in survival rates is due to advances in screening
especially through mammography and other early detection methods that are
decentralized across the country and better treatment. In Western countries, there are
cancer control programs that entail active recruitment strategies for breast cancer
screening programs such as Sending letters, making phone calls, mailing educational
materials and organizing training activities with reminders for the women. These are
actions that increase the attendance rate of women invited to a community breast cancer
screening service. Some combinations of effective actions (such as a letter and phone
calls) have important effects and have been tested mostly among the lower
socioeconomic groups of women (Bonfill, Marzo, Pladevall, Marti &Emparanza., 2009)
Despite this advances, in the United States, a third of breast cancers cases are being
diagnosed at a late stage when treatment is less effective. The study conducted by Centre
for Disease Control found lower acceptance of screening and late presentation of
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symptoms in low income and ethnic minority communities who also had long delays in
getting their diagnosis and treatment. Many patients are unaware of the symptoms of
cancer and health literacy, cultural attitudes towards seeking medical care, fear and
embarrassment of cancer diagnosis and difficulties navigating the healthcare system all
play a part. Physicians also add to the delay by failing to recognize sentinel signs and
triage the right patients forward for further investigation (CDC Report 2010).
In the United Kingdom, according to research by the government’s director of cancer
services, up to 10,000 people die of cancer every year because their conditions are
diagnosed too late due to several factors such as; ethnicity, social deprivation and gender.
Social-economic status is a powerful driver of women accepting breast cancer screening;
deprived population seems to have later stage presentation in breast cancer compounding
the potential effect of inequalities of breast screening uptake. There is compelling
evidence that certain ethnic sub-groups in the UK have lower participation rates than the
general population despite the availability of cancer screening services and high
proportion of informed population about cancer (Weller and Campbell, 2009).
Managing breast cancer in low and middle income countries poses a different set of
challenges including access to screening, stage at presentation, and adequacy of
management as well as availability of therapeutic interventions. The infrastructure and
resources for routine mammography are often unavailable. In these countries, breast
cancer is usually diagnosed at the late stages, and due to inadequate resources, women
with breast cancer may receive inadequate treatment or palliative care. (Arafat, Temraz,
Mrad, and Shamseddine. 2010)
Many barriers are identified for breast cancer patients in low and middle income
countries which may correlate with lower incidence and higher mortality in those
countries compared to high income countries. These barriers include the lack of breast
cancer awareness due to poor health awareness and education, lack of screening
programs due to lack of government support and inadequate funds, social barriers to early
diagnosis and treatment due to low priority for women health issue in predominantly
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patriarchal developing societies, fear of loss of employment, and the social taboo of
cancer and misconception about cancer treatment and outcome, lack of standardized
treatment protocol with diversity of clinical practices, healthcare standards and
infrastructure and finally follow-up data and the lack of mortality data.
In Asia, breast cancer incidence is lower than in western countries; however, the
incidence is rising at a more rapid rate than in western countries. Breast cancer is the
leading cancer among Asian women at 31.3% and its diagnosis is generally at late stages
compared to western countries (University of Malaya 2010). Late diagnosis of breast
cancer in Asia is mainly due to various factors; ignorance and poor education among
Asian women; geographical isolation and inadequate access to medical care, fear of
surgery and belief in traditional treatment and absence of screening program as well as
financial problem. In Malaysia, the delay in presentation of breast cancer was attributed
to a strong belief in traditional medicine, the negative perception of the disease, poverty
and poor education coupled with fear and denial.
In Latin America, breast cancer is the most commonly diagnosed cancer among women
and more frequent at an advanced stage. This likelihood of diagnosis at an advanced
state is present when education level, income, and detection method are controlled
factors. Potential reasons for delayed diagnosis include less access to mammography
screening, lower confidence in the value of screening and use of mammography, longer
intervals between mammography, and delayed follow-up for abnormal result due to
economic factors and fear and denial of disease (United States Cancer Statistics 2009).
As much as 95% of cancer patients in the African countries are diagnosed at late or end
stage of the disease. The delayed diagnosis for these patients is due to the low level of
cancer awareness between the population and the health workers, culture and constraints
on access to specialized care that is usually nonexistent. Community dwelling women in
Nigeria have poor knowledge of breast cancer and very few practice self-breast
examination and clinical breast examination. In addition, education appears to be the
major determinant of level of knowledge and health behavior among the Nigerian
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women. The Free State province in South Africa has a low BSE, CBE mammographic
screening rates attributed to a lack of awareness of the rising incidence of breast cancer in
the province by the public in general and probably also by the healthcare professionals
(Lepecka, Jakiel, Krasuka & Stanislawek, 2007).
In Egypt, patient mediated factors influencing late stage presentation of breast cancer
include; lack of knowledge about BSE and not having a previous CBE or a mammogram.
Social, financial and time constraints as well as long travel time and lack of pain are also
other factors leading to late stage presentation of breast cancer (Psycho-oncology 2010).
Cancer is relatively new concept in Northern Uganda where people demonstrate a
misconception or ideas of acceptable health seeking behavior, individual seem to measure
health by the level of pain. Due to competing priorities, like providing for the family,
people delay hospital visits until the pain becomes too distracting from daily activities.
This breast cancer detection behavior directly affects chances of survival (Karen Im
2010). About 90.73% of breast cancer patients in Tanzania are diagnosed at advanced
stage with about half of the tumor being ER-/PR. There are numerous patient mediate
barriers to seek care which include; inability to pay for medical care and beliefs, fear,
cultural factors and ignorance and delay in referrals from peripheral areas (Lepecka et al,
2007)
Statistics in Kenya has shown that about 50 Kenyans die daily from various forms of
cancer according to pact Kenya cancer assessment in Africa and Asia 2010, (Kenya
Department of Research 2011). As cancer treatment is improving in the developed world,
in Kenya, these advances are yet to be realized. This is due to deficiency of resources,
infrastructure, and trained personnel. Cancer of the breast (23.3%) and cervix (70.0%)
remain the highest occurring cancers affecting women in Kenya (Cancer Incidence
Report, 2006).
Most cancer patients seen in Kenya are diagnosed with late stages when treatment is
difficult if not impossible. This trend is obviously associated with prolonged morbidity
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and increased mortality from many preventable and manageable cancers. A study
conducted in Western Kenya reported key to access as including fear of positive
screening result, lack of awareness about the screening services and lack of finances to
buy the service (Were, Nyaberi, & Buziba, 2011).
According to the department of Research, 2011, factors that are back tracking the fight
against cancer in Kenya, are; inadequate facilities, few specialists, high cost of treating
cancer, lack of accessibility to treatment and sedentary lifestyle. In Nairobi, breast cancer
is the most frequent cancer among female accounting for 33.5% of the 20 major
cancerous ailments among women (Kemri Cancer Statistics 2006). Most of the reported
cancer a diagnosed at late stages when very little can be achieved with therapeutic
intervention. According to cancer research UK 2012, late stage diagnosis was more
common in women from deprived backgrounds.
This research study aims at investigating social-economic factors and the acceptance of
breast cancer screening, which is the leading cancer among women in Nairobi. This
study targets market women who have low resources and are medically underserved
group and are more likely to develop cancer and die from it.
In Kenya, cancer infrastructure is inadequate and some cancer management options are
not available. Most breast cancer cases are diagnosed at an advanced stage when there is
little that can be done. Breast cancer treatment is very expensive and many women with
financial resources have to travel to countries like India, South Africa and USA for
specialized treatment (Leigh mc Adam 2010). Women have a higher risk of breast cancer
and there is therefore urgent need for them to accept and be screened for breast cancer to
avoid late diagnosis that makes treatment difficult if not impossible.
Studies have been done on the influence of various factors on the acceptance of breast
cancer screening among women in different setups around the world. Most of these
studies have mainly focused on women attending hospital or those that have been
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screened before. In Kenya, similar studies have been done on cancer screening
acceptance in hospital setup for women attending hospital or those women who have
been screened before. There are inadequate studies that have looked at how these factors
are influencing the acceptance of breast cancer screening in low resource areas and
among those women not attending hospital and have never been screened for breast
cancer before.
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