Breast cancer awareness in reproductive women in the low- and middle-income countries: a scoping review

Cancer is currently a major global health concern, with an estimated 10 million deaths in 2022 alone, according to the World Health Organization (WHO).¹ Cancer-related mortality is particularly prevalent in low- and middle-income countries (LMICs), where lower incidence rates may be correlated with higher mortality rates compared to high-income countries. By 2035, it is estimated that 2/3 of new cancer diagnoses will occur in developing countries.² On the other hand, breast cancer (BC) is the most commonly diagnosed type, accounting for approximately 2.26 million cases worldwide.³

BC is an increasingly urgent problem in LMICs, where historically low incidence rates have been rising by up to 5% per year and mortality rates remain high or continue to rise.³ In 2010, over half of the 425,000 BC deaths occurred in LMICs rather than in high-income countries.⁴ BC cancer deaths disproportionately affect individuals in LMICs, with 5-year survival rates >90% in high-income countries compared to 66% in India and 40% in South Africa.^4,5

There is substantial evidence that a lower level of education and income are associated with patient delay, lack of information about breast health, restricted choices for early detection due to limited access to routine care and examination, and lack of access to mammography and high-quality treatment options.^6,7 Reducing the incidence of BC in developing countries could have a significant impact through limiting alcohol consumption, maintaining an optimum body weight, engaging in regular physical activity, and avoiding postmenopausal hormone replacement therapy.⁶ Barriers to reducing the incidence of BC include a lack of awareness due to poor health education.⁸ A systematic review suggests that to effectively reduce patient delay, interventions should focus primarily on increasing accessible and affordable healthcare access, as well as improving BC awareness.⁷ Understanding the importance of early detection of BC plays a crucial role in reducing mortality rates and improving the prognosis of the disease.⁹

It is evident that less emphasis is placed on screening to lower cancer prevalence in LMICs. This is consistent with other research, which suggests that most LMICs are focused mainly on maternal health in terms of resources, while cancer overall, and BC, takes a backseat.¹⁰ Furthermore, policymaker awareness remains low in LMICs regarding the cost-effectiveness of BC screening and early detection as a “best buy” opportunity to reduce health costs. This, coupled with a lack of research on cost-effective screening and early detection methods, as well as little community awareness about BC being a treatable disease, results in most LMICs losing a large number of women at an early age.¹¹ Previous studies show that in 2017, 38.0% of Nigerians had poor knowledge about breast self-examination (BSE) and 67.3% were unaware of mammograms.¹² Moreover, in 2021, 41.7% of nursing students in India had average knowledge of BSE, while 10% had below-average knowledge.¹³

No previous studies have provided a comprehensive summary of the current situation of breast cancer awareness in LMICs. Therefore, our study aimed to examine the levels of BC awareness and knowledge, the factors that influence them, and the potential interventions to improve them. We addressed the following research questions: “What is the level of BC awareness among reproductive women?” “What are the factors that influence BC awareness among reproductive women?,” and “What are the effective programs or interventions to increase BC awareness among reproductive women?”

We have chosen the scoping review method as the most appropriate approach for our research, as our aim is not to draw conclusions from the synthesis of effectiveness, but rather to map the available evidence and identify knowledge gaps.¹⁴ To ensure a rigorous and transparent process, we used a modified 5-step of Arksey and O’Malley scoping review framework by Levac et al.¹⁵ Within this framework, we are following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Review.¹⁶

The 5-stage framework includes: identifying the research question, identifying relevant studies, selecting studies, extracting data, and collating, summarizing, and reporting the results.

A total of 3350 articles were identified through database searching and other sources, including Google Scholar and citation searching. After screening the titles and abstracts, 3267 articles were excluded. The full texts of 56 articles were assessed for eligibility based on the inclusion and exclusion criteria. Of these, 23 articles were excluded for reasons listed in the PRISMA flow diagram (Figure 1). Ultimately, 33 studies were included in this review.

Figure 1.

3.2.

Knowledge and awareness, prevalence, and distribution in included studies

As shown in Figure 2, out of the 33 articles included in this review, 45.6% reported a good level of knowledge, and 24.2% reported good awareness of the study’s main findings. Meanwhile, 15.2% and 30% of the included studies reported poor awareness and knowledge, respectively, as their main findings.

Figure 2.

3.3.

Influenced factors of the knowledge and awareness of reproductive women

Influencing factors were identified in 3 categories: sociodemographic, personal, and external factors. Sociodemographic factors include family history, personal history, marital status, age, religion, income status, place of residence, and occupation. Personal factors include self-efficacy, education, and perceived susceptibility. External factors were only mentioned in the context of advertisements promoting awareness. Of the 12 influencing factors, education was the most frequently mentioned factor in the included studies (n = 12). Religion and advertisements promoting awareness were only mentioned in one study each, while the other factors were mentioned in more than one study. Detailed information is presented in Figure 3.

Figure 3.

3.4.

Recommendations for future interventions and programs

In summary, Figure 4 shows that there are 3 main types of recommendations for interventions and programs. Educational interventions were mentioned in >72% of the recommendations in the included studies. Secondly, several of our findings suggested knowledge promotion and preventive health programs (6/33 studies). The last type of recommendation was for public health and social measures. Additionally, social media and religious institutions can assist in communicating information about BSE and BC.

Figure 4.

We conducted a scoping review of 33 studies on BC knowledge and awareness among reproductive women aged 15–49 in LMICs. The purpose of our review was to examine the patterns of knowledge and awareness based on the main findings of the studies, to explore the factors that influence them, and to identify the gaps and recommendations for future research. Our results indicate that most of the studies reported high levels of knowledge and awareness, but some also found low prevalence of knowledge among certain groups. We classified the factors that affect knowledge and awareness into 3 categories: socio-demographic, personal, and external. The socio-demographic category was the most frequently cited in the studies, with various factors such as age, education, income, and marital status. The main recommendations from the studies were to implement educational programs, health prevention strategies, and social interventions to increase BC knowledge and awareness.

Most of the studies in our review reported high levels of knowledge and awareness among the participants. This is a crucial first step to promote BSE as an early detection method. BSE is a simple and cost-effective strategy that can help women achieve both breast awareness and early diagnosis of breast abnormalities.^11,49 Early detection of BC can increase the chances of successful treatment and reduce the mortality and morbidity associated with the disease.³¹ Therefore, it is essential to empower women to perform BSE regularly and correctly, especially in LMICs, where access to other screening modalities and health services is limited.^34,50 However, there are also sociocultural barriers that may prevent women from practicing BSE or seeking professional help for breast problems, such as stigma, fear, lack of support, or low health literacy.⁵¹ These barriers need to be addressed through culturally sensitive and tailored interventions that can enhance women confidence and motivation to take care of their breast health.⁵²

BC knowledge and awareness can motivate women to adhere to the screening guidelines and identify any breast problems at an early stage.^53,54 Women aged 20–30 years should have a CBE by a healthcare professional every 3 years, while women aged 40 and above should have it every year.²⁶ This can enable the healthcare providers to deliver more effective and timely treatment and also track the patient’s condition more closely.⁵⁵ Early detection of cancer can improve the outcomes and survival rates of cancer patients by providing care at the earliest possible stage.⁵⁶ It can also reduce the mortality and morbidity associated with the disease, as well as the costs of treatment and care. As such, it is an essential public health strategy in all settings. However, there are challenges and barriers to implementing successful early detection programs, including lack of awareness, accessibility, affordability, quality, and equity of cancer services.⁵⁷ These barriers must be addressed through comprehensive and coordinated policies and interventions that involve multiple stakeholders and sectors.⁵⁸

Early detection of cancer is vital for improving the outcomes and survival rates of BC patients.⁵⁹ Early detection of cancer comprises 2 components: early diagnosis and screening.⁶⁰ Early diagnosis aims to detect symptomatic patients as early as possible, while screening involves testing healthy individuals to identify those with cancers before any symptoms appear, which is particularly relevant to cancers of the breast.^52,61 Screening is a more complex and resource-intensive strategy that requires adequate capacity and infrastructure to avoid delays in diagnosis and treatment.⁶² Screening programs should be undertaken only when their effectiveness has been demonstrated, when resources are sufficient to cover the target group, when facilities exist to confirm diagnoses and ensure treatment, and when the prevalence of the disease is high enough to justify the effort and costs of screening.^60,63 It should be noted that promoting early diagnosis is a necessary prerequisite to implementing population-based screening in certain situations.⁵⁹ This is because early diagnosis can enhance outcomes for all BC patients, whereas less than half of BCs are diagnosed through screening, even in the most effective programs.^27,55 As such, efforts should initially prioritize early diagnosis over opportunistic or organized screening until the requisite infrastructure and organizational requirements are established. Health planners, policymakers, and other stakeholders, including clinicians, educators, community members, and advocates, should be cognizant of the health system requirements and overall costs of these approaches tofor early detection of BC to make effective investments, plans, and policies.⁵⁹

The results of our scoping review revealed that education, age, having family members with BC, and marital status were the most frequently reported sociodemographic factors that influenced BC knowledge and awareness among reproductive women in LMICs. These findings are consistent with previous studies that have found similar associations between these factors and BC awareness.^64–66 Education is an important factor that affects women’s health literacy and access to information about BC. Women with higher education levels tend to have more knowledge and awareness of BC symptoms, risk factors, screening methods, and treatment options.⁶⁷ They are also more likely to practice BSE and seek professional help for breast problems.⁶⁸ Age is another factor that influences women’s BC knowledge and awareness. Women’s risk of developing BC increases with age, especially after menopause.⁶⁹ However, younger women may also be affected by BC, especially in LMICs where the incidence of premenopausal BC is higher than that in high-income countries.^26,70 Meanwhile, having family members with BC is a factor that can increase women’s perceived risk of developing the disease.⁶⁵ Women who have a family history of BC may be more aware of the genetic and hereditary aspects of the disease and may seek genetic testing or counseling.⁷¹ They may also be more motivated to adopt healthy behaviors and lifestyle changes that can reduce their risk of BC.⁷² In addition, the marital status of women may have an effect on the risk of developing female BC. However, the evidence is not conclusive whether marital status is an independent risk factor for BC.⁶⁶

Educational Educational programs are a key component in raising awareness and sharing knowledge. The reason why education intervention was the most frequently mentioned in the included study (>72%) is to decrease the burden of BC morbidity and mortality by enhancing self-care abilities and increasing awareness of the disease.⁷³ Training is a low-cost strategy that can be used to increase knowledge of BC and BSE, reaching a large number of people with limited resources.^18,62 In terms of health prevention planning, BC awareness, education, public health, and social measures are all important.^27,52 Most people desire effective BC prevention education, which fosters healthy behaviors, not only through teaching, but also through using the breast as a model. To ensure early detection and reduce the mortality rates associated with BC, screening programs should also be implemented by healthcare professionals.^74,75

The implications of these findings suggest that interventions tailored to the specific needs and preferences of different groups of women, based on their socio-demographic characteristics, are necessary. Such interventions should aim to increase knowledge and awareness of BC among women, as well as their self-efficacy and intention to practice early detection methods. Moreover, these interventions should involve multiple stakeholders and sectors, including health professionals, educators, media, community leaders, policymakers, and civil society organizations, to create a supportive environment for women’s breast health. Additionally, public health and social measures should include the development of a public screening and education program through the healthcare system that focuses on low-educated, younger, single women without a family history. The government health administration, at both national and international levels, should play a role in raising awareness among the general public by organizing seminars. Furthermore, health professionals should promote awareness among the general population, and rural residents should have access to healthcare facilities, which should be facilitated by the government.

Our study had several strengths that enhanced the quality and comprehensiveness of our scoping review. First, we focused on women of reproductive age to capture the full spectrum of the general population of women in LMICs, who face multiple challenges and disparities in accessing health care services. Second, we conducted a systematic and comprehensive search of the literature, using not only electronic databases, but also manual searching on the academic search engine (Google Scholar) and citation searching, to identify and retrieve relevant studies from various sources and disciplines. Third, we adhered to the guidelines established by Arksey and O’Malley’s framework for scoping reviews, which provided a rigorous and transparent method for mapping and synthesizing the available evidence on our topic.

This review has several limitations that warrant consideration. Firstly, we excluded non-peer-reviewed literature from our search and only utilized reputable, worldwide, scientific databases. While this may have enhanced the quality of the studies retrieved, it may have also resulted in a lower number of studies from certain WHO regions, particularly those from countries where English is not the primary language of academic writing and publication. Secondly, despite conducting extensive database and manual searches, we may have inadvertently overlooked some relevant research. As such, we recommend that future reviews on this topic incorporate a broader range of sources and languages to ensure a more comprehensive coverage of the literature. Additionally, this review highlights several avenues for future research, including conducting more studies in under-represented regions and countries, utilizing more consistent and valid measurement tools and indicators, examining the factors that influence women’s awareness and knowledge in different contexts and settings, and evaluating the impact of various interventions and strategies, to improve women’s awareness and knowledge about BC in LMICs.

This scoping review mapped and synthesized the available evidence on the prevalence of awareness and knowledge of BC among women of reproductive age in LMICs. The findings revealed that there is a significant gap in the literature on this topic, as most studies focused on specific regions or countries, used different measurement tools and indicators, and reported varying levels of awareness and knowledge. This indicates that there is a lack of standardized and comparable data on the awareness and knowledge of BC in LMICs, which hinders the development and evaluation of effective interventions and policies to address this issue. The findings also suggested that there is a need to enhance the knowledge and awareness of not only BC but also self-examination in women, as these are crucial for early detection and treatment of the disease. Therefore, this review has important implications for healthcare providers, researchers, policymakers, and governments, as they should pay more attention and take more action to raise the awareness and knowledge of women about BC in LMICs. This could help women to seek timely medical care, improve their survival outcomes, and reduce the burden of BC mortality.