Determinants of breast cancer early detection for cues to expanded control and care: the lived experiences among women from Western Kenya

Determinants of breast cancer early detection for cues to expanded control and care: the lived... Background: Estimately, 70–80% of cancer cases are diagnosed in late stages in Kenya with breast cancer being a common cause of mortality among women where late diagnosis is the major ubiquitous concern. Numerous studies have focused on epidemiological and health policy dynamics essentially underestimating the determining factors that shape people’s choices and cues to health care service uptake. The study sought to evaluate the knowledge, attitude and health seeking behavior towards breast cancer and its screening in a quest to explain why women present for prognosis and treatment when symptomatic pointers are in advanced stages, impeding primary prevention strategies. Methods: Eight focus groups (6–10 members per group) and four key informant interviews were conducted among adult participants from rural and urban settings. Sessions were audio-recorded and transcribed. A thematic analysis of the data was based on the concepts of the health belief model. Data analysis was conducted using NVIVO10. Results: Most women perceived breast cancer as a fatal disease and conveyed fear of having early screening. Rural women preferred self-prescribed medications and the use of alternative medicine for long periods before presenting for professional care on suspicion that the lump is cancerous. Accessibility to equipped health facilities, lack of information to establish effective follow-up treatment and low-income status were underscored as their major health seeking behavior barriers whereas, urban women identified marital status as their main barrier. Key informant interviews revealed that health communication programs emphasized more on communicable diseases. This could in part explain why there is a high rate of misconception and suspicion about breast cancer among rural and urban women in the study setting. Conclusions: Creating breast cancer awareness alongside clear guidelines on accessing screening and treatment infrastructure is critical. It was evident, a diagnosis of breast cancer or lump brings unexpected confrontation with mortality; fear, pain, cultural barriers, emotional and financial distress. Without clear referral channels to enable those with suspicious lumps or early stage disease to get prompt diagnosis and treatment, then well-meaning awareness will not necessarily contribute to reducing morbidity and mortality. Keywords: Breast cancer, Early breast cancer screening, Focused group discussions (FGD), Key informant interviews * Correspondence: khayekachris@yahoo.com School of Pharmaceutical Science and Technology (SPST), Health Science Platform, Tianjin University, 92 Weijin road, Nankai District, Tianjin 300072, People’s Republic of China African Population and Health Research Center (APHRC), P .O. Box 10787-00100, Nairobi, Kenya Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kisiangani et al. BMC Women's Health (2018) 18:81 Page 2 of 9 Background Methods Cancer is the third highest cause of mortality in Kenya after Study design infectious and cardiovascular diseases. Leading cancers are The qualitative research was conducted between November breast and cervical for women [1, 2]. Seventy to 80 % of 2013 and March 2014. A qualitative design using focus cancer cases are diagnosed in late stages. Like many other group discussion (FGD) and key informant interview (KII) Non-Communicable Diseases (NCDs) breast cancer methods was applied as an ideal approach to explore progresses slowly, degenerates to devastating disabilities perceived motivators and barriers to healthy behaviours and the management costs are high if not timely diagnosed [24]. The items in the FGD and KII were developed based and treated. There is better prognosis, greater chances of on the concepts of the health belief model [16, 25–29]. successful treatment and high survival rates when detected Interview guide for the focus group discussions and at early stages. Methods such as clinical breast exams in-depth interviews (key informants) are as provided (see (CBE), mammograms and breast self-examinations (BSE) Additional file 1). The concepts included; percieved severity have been used as main approaches [3, 4]. of breast cancer, perception of susceptibility to breast Health care access is considered a multidimensional con- cancer, perceived benefits of breast cancer early detection cept encompassing both financial and non-financial dimen- measures, perceived barriers to breast cancer early detec- sions [5, 6]. It has broadly been defined as the degree of fit tion measures, self-efficacy and cues to action. The concep- between a patient’s socioeconomic characteristics, the tual framework for the qualitative interview was adapted as health system, and health services organization [5, 6]. The earlier reported [30, 31]and is showninFig. 1.This five core components of access that have been outlined are: approach was selected because FGDs and KIIs can be acceptability, affordability, accessibility, accommodation, undertaken in naturalistic settings which may stimulate and availability [5–9]. In Kenya, tremendous gains have more openness and candor [32, 33]. Also the group inter- been made in the recent past on affordability, accommoda- action has the capability to elicit information and insights tion, and availability of cancer screening and treatment that are less accessible during individual interviews [34]. services whereas much more effort still needs to be put on Probing by the moderator allowed in depth exploration of accessibility and acceptability [8, 9]. Compelling findings on unanticipated issues as well as an opportunity to clarify and breast cancer in Kenya still show that most women are not enhance understanding of responses [33]. aware of signs and symptoms of breast cancer due to cul- tural diversity views and limited education and awareness Study setting and participants programs with a lag on clear referral channels information Kakamega is aCountyinWestern Kenyalying about30 empowerment [8, 10–14]. This considers the fact that, KM northofthe Equator. The countyhas apopulation of there are varied underlying information and awareness about 1.7 million (KNBS, 2010) with a population density factors among Kenyan women on early cancer screening of about 544 people per square kilometer and is Kenya’s and on why and under what conditions they would take second most populous county after Nairobi [35]. According action towards medical attention for prevention or early to the 2009 census, 15.2% of the population lives in urban screening and treatment [4, 15, 16]. areas. Of the approximately 1.7 million people,48% are male As studies shed more understandings on the the risks and 52% female. The population is relatively poor with a and benefits of early breast cancer screening, indepth povertyrateof53% [35]. The main health facilities in the understanding of women perceived risk and barriers have county and its environs are: Kakamega General Hospital, become integral [13, 17, 18]. The insights can help influ- Central Maternity and Nursing Home, Butere district ence women choice of approaching early screening and hospital, Malava district hospital, Mumias district hospital, treatment options or risk-reduction strategies and effective Matungu, Manyala and Navakholo sub-district hospitals, follow-up treatment [17–19] in a targeted approach that Kima Mission Hospital and Kimilili District Hospital. resonate with their gendered socio-cultural role; their The researcher divided the 12 constituencies into two perceived susceptibility, severity, benefits and perceived groups; urban and rural using Kakamega First County health needs [6, 20]. The study thus generates and Development Plan, 2013. Map of the study areas, enhances the pool of evidence that would aid inform the Kakamega couty constituencies and study locations (see development of local cancer information, education and Additional file 2). Urban groups include: Mumias West, communications (IEC) tailored for communities in Kenya Lurambi, Shinyalu, Mumias East and Butere whereas incorporating approaches that fully engage the target pop- Rural groups comprise: Matungu, Khwisero, Malava, ulations [21]. As a result, potentially promote optimization Ikolomani, Navakholo, Lugari and Likuyani. Two con- of the existing and upcoming national health systems for stitntuencies for rural settings (Ikolomani and Likuyani) cancer management under the vision 2030 and beyond as and urban settings(Mumias West and Lurambi) respect- envisaged under the cancer awareness, community en- ively were randomly selected. Eligible participants were gagement plan [6, 14, 21–23]. selected using a purposive sampling method. Thus, for Kisiangani et al. BMC Women's Health (2018) 18:81 Page 3 of 9 Fig. 1 Conceptual framework for the qualitative interview. Adapted from [30, 31] the FGDs, homogenity on particular characteristics was where necessary. Information from KII (the first one to considered; (in this case it was for gender, age and rural be conducted) helped inform some of the questions to or urban) and recruited from the communities of the ask in FGD. Thus, gaining further understanding on the randomly selected constituencies. Convenience sampling validity of DPHN perspective in resonance to the (number of locations and sub locations per consitutency population they attend to and considering they often for more objective representation) was utilized for selec- provide inputs in appraising government health sector tion of the FGDs members by the researchers with the operational guidelines and policies which have a direct help of local leaders (chiefs and sub-chiefs) through their bearing on the populations they serve. Focus groups documented community governance records. Thus, the lasted between 43 to 65 min. Rural focus groups were FGDs were conducted in two groups: young women of conducted in Swahili while discussions with urban age group 18–35 and older women of age group 36–60 women took place in Swahili and English. The items in emanating from either urban or rural concsitituency. FGD interviews were initially formulated in English then Hence, 72 participants all above 18 years were inter- translated into Swahili for the use in the different study viewed, and comprised of four key informants and 68 locations. Data collected in Swahili versions were trans- members of 8 FGDs with between 6 and 10 participants lated back to English to ensure consistitency with the per FGD. Two (2) focus groups were drawn from each data collected in English versions. The five-phase cycle constituency. For each set of 2 groups, 1 FGD consti- of compiling, disassembling, re-assembling (and array- tuted women of age 18–35, and another of women of ing), interpreting and concluding were used to process age 36–60. One (1) key informant was drawn from each the data as earlier described [36]. constituency. Key Informants were the four District Public Health Nurses (DPHN) that were from the four constituencies where the FGDs were done. The DPHN Data analysis were considered because, they interact with a significant All the data from the KIIs and FGDs were then uploaded proportion of women in these communities and there- to the Computer Assisted Qualitative Data Analysis Soft- fore considered to be more knowledgeable of what the ware (CAQDAS) QSR Nvivo10 for windows for manage- women face in obtaining early breast cancer screening. ment and analysis. Coding was done as earlier described Consented participants were allocated to a focus group [36] with level 1 to level 3 coding with the following session or Key informant interviews (KII) based on the major emerging categories from the level three coding: respective eligibility cirteria. health seeking behavior of breast cancer and its screen- ing, knowledge of breast cancer and its screening, atti- Data collection tude towards breast cancer and its screening and breast The items in the focus group discussion interviews and health promotional strategies. Comparisons between the key informant interviews were developed based on the four groups; urban rural, 18–35 year old women and concepts of the health belief model (as above-mentioned those aged 36–60 years were made as categories and detailed). The concepts were pretested with small emerged. Findings were reported per the themes/topics groups outside the target study area and revisions made that emerged. Kisiangani et al. BMC Women's Health (2018) 18:81 Page 4 of 9 Results their women to go for cancer screening as it is a disease Findings from the focus group discussions and key inform- that is associated with terminal health complications ant interviews are presented per the main categories from equating it to be even more worse than HIV/AIDS and level 3 coding that emerged. getting to know makes it even more hard to live with the new reality. Contrary, rural women (up to 75% of rural Category one: Health seeking behavior of breast cancer participants) identified long distance to health facility, lack and its screening of information on breast cancer and its screening and Sixty-eight women aged 18–60 years (age: 18–35: 36 and low-income status as major health seeking behavior bar- 36–60: 32) from the selected rural and urban constituen- riers. An older woman from rural group 4 said: cies of Kakamega county Kenya participated in eight focus groups (average 8.5 participants per group). Of these 63 “Ignorance and lack of information on the importance (92.6%) were Christians and 5 (7.4%) were Muslims. of cancer screening hinders women from seeking early Participants were predominantly married (72.1%). The breast cancer screening”. educational level of the respondents varied considerably; 45.6% had primary education, 35.3% secondary, 11.8% A younger woman from rural group 1, said: middle level college training and 2.9% university degree while the rest had no formal schooling. There were 32 “The long distance to the cancer facility would cost women from the rural setting and 36 urban. The average a lot of transport fare that I cannot afford and this family size was 6 persons, with an average of 4 children makes it difficult for me.” per woman. All working women had government medical cover, the National Health Insurance Fund (NHIF) An interview with Key informant revealed that the through their jobs, granting coverage for health service health centres and hospitals do not have enough nurses to use at governmental facilities for themselves and their perform regular breast cancer screening. She narrated: dependents. Despite having NHIF cover, the women expressed a generalized preference for private health care “The number of staff in the hospitals should be providers. They however explained that, their choice to increased. Sometimes you will find there is only one use public rather than private services was often mediated nurse who has to do everything in a hospital. When by a series of social, economic, and geographical consider- a woman comes in for a BCS, the nurse is most likely ations. None of the women had private health insurance to attend to the patients whose lives are at risk first. cover instead self-help savings and credit groups, com- There should be devolution. The number of staff monly known as chamas were common source of building should be increased.” financial capacity and borrowing among the women. The vast majority of women rated their health status as good. Through indepth discussions it was evident cultural There were disparities between the urban and rural religion orientation was a contributing barrier among when it came to health seeking behavior barriers (see rural women compared to their urban counterparts. A Additional file 3). Most urban women (from all the 4 rural participant from rural group 3 said; urban FGDs) identified marital status as their major barrier to early breast cancer screening. Specifically, “Some women go to churches that believe in prayers young-urban women explained that married women for healing, the churches do not allow their followers have to consult and at times get not only advice but also to go to the hospital. Such women do not go for breast permission from their husbands before seeking any cancer screening.” medical help or undertaking social commitments that has an impact on their health. An urban woman from The study further revealed that most women are skeptical group 7 to symbolically contextualize the challenge of having early breast cancer screening as attributed to fear depth narrated: of getting a positive breast cancer diagnosis; stigmatization associated with it and breast cancer related cultural beliefs “Some men do not allow their women to go to the alongside misconceptions as well as the, what next? doubts. hospital. Most men do not even allow their women The action taken when a woman realized she had a breast to go out of the homestead and ‘fetch water for lump was influenced by the community perception of the domestic use’, how then will they even allow origin of the disease for the older urban participants, con- women to go for cancer screening at the hospital?” ventional practices and beliefs for most rural participants and level of knowledge by younger-rural women. Most They went further to explain that as the head of the urban women described the community perception and home, some husbands would have difficulties in allowing association of breast cancer to promiscuity, infidelity, and Kisiangani et al. BMC Women's Health (2018) 18:81 Page 5 of 9 equating it to HIV/AIDS thus hindering women who sus- “I know they are cells that multiply in the breast pected a lump in their breast was cancerous from seeking leading to death.” early treatment in hospitals. An older woman from the urban group 8 narrated: Specifically, young urban participants seemed more knowledgeable about lifestyle issues that predispose indi- “If a woman is known to be sleeping around with viduals to breast cancer. They mentioned smoking, too many men, and she discovers that she has breast much sugar and salt in food, use of bleaching pills and cancer, she will prefer not to go and seek treatment self-medicated pills. A woman in urban group 7 said: because she is afraid that she might go to the hospital, get tested for HIV and told that she has AIDS.” “I know that it is brought about by smoking and using a lot of fat in your food.” Rural women on the other hand preferred using herbal remedies, self-medicating with painkillers or going to trad- Other misconceptions across the women included being itional medicine men for complementary and alternative born with “risky bugs” in their breasts, breast cancer being remedy when they suspected they had a cancerous lump a consequence of having HIV and prostitution as well as in their breast. A woman from rural group 3 said: surgery of the breast being associated with breast cancer status and death. “Women believe it is a sore, so we take traditional herbs called “miyeka”.” Category three: Attitudes of women toward breast cancer and its screening We also established that younger-rural participants and Most women were concerned of breast cancer and were older participants were not aware or clear of simple overwhelmingly convinced that it is a serious terminal methods such as breast self-examination or where they disease with no cure. Terms such as ‘deadly and death’ could get early breast-screening services. Several older were commonly used in the description of breast cancer. participants asked to be taught how to detect a lump in A participant in rural group 2 said: their breast while younger women explained that they were not confident on performing breast self-examination “Breast cancer is a death sentence.” on themselves. A young participant explained in frustra- tion how nurses instructed them to palpate their breast Another participant in rural group 1 said: but she did not understand how palpation was done or what the nurses meant by palpate. When asked how to “I understand that it has no cure. It is an incurable check for lumps in their breast, a participant from urban disease.” group 8 said: Several participants also described the perceived serious- “We do not know. You should teach us on how one ness of the disease as extremely dangerous and incurable. A knows that they have breast cancer.” young woman in urban group 5 stated: This is despite the fact that health centres in Kakamega “The women in the community believe that breast County schedule a day in a month for breast health edu- cancer is a disease that does not have a cure and cation. A key informant from a rural group explained so will not bother to go to the hospital.” that most facilities in the county conduct breast screen- ing at facility level once a month. However, she also Participants were also afraid of CBE. A participant from added that it was likely that women did not know that urban group 8 narrated: they could access such services for free due to lack of information. “I do not think going for breast cancer screening is a necessity. One woman that I know went for breast cancer screening and was told that she had it and Category two: Knowledge of breast cancer and its that her breast had to be removed... When her breast screening was cut, the cancer spread throughout her body and Younger participants seemed to have a better comprehen- following that, I and many of my friends who knew sion of breast cancer, its early manifestations, early breast her can’t go to the hospital.” cancer screening and predispositions’ to the disease com- pared to older participants. A participant from rural group Some urban participants seemed well aware of the 1 defined breast cancer as: benefits of early breast cancer screening. They noted that Kisiangani et al. BMC Women's Health (2018) 18:81 Page 6 of 9 knowing their breast cancer status early would result to The participants also asked for free and regular breast the early treatment of the disease and this would increase cancer screening services to be made available not only in the chances of survival. They also explained how early mother-child health clinics but also in the overall hospitals screening uptake reduces the high cost of treatment of the services. When the women were asked on the best channel disease if it is detected early. A woman from urban group of communication of information on breast cancer and its 6said: screening, urban participants suggested the use of media, and mother-child health clinics. Most young participants “If I am found with cancer at an early stage, it means suggested use of community health workers (CHW), social that I will not spend much on the treatment of the media and text messages as the best avenues for the com- disease. It will be cheaper for me.” munication of information. Rural participants suggested the use of community health workers. A rural participant said: Despite this knowledge among some of the partici- pants, they were still sceptical of having early breast can- “Through seminars- they should take CHW’son cer screening as it would lead to psychological stress, seminars, and when they come they should educate depression and even early death unlike when they were the community on breast cancer by doing door to not aware. door education.” Category four: Breast health promotion strategies Older women suggested use of door to door education, Most of the participants had very limited knowledge of churches, village meetings (barazas) and village chief’sas breast health awareness programs. Participants could the best channel for communication of information on only mention programs aimed at communicable diseases breast cancer and its screening. Key informant 2 suggested: (Malaria and HIV) awareness creation. Participants from rural group 2 said: “Verbal health education- use of wall charts, the mass media, chief barazas and use community leaders “There is no much emphasis on breast cancer (church leaders and chiefs to talk to them).” awareness campaigns.” The participants pointed out the reason why they do Discussion not have much information on breast cancer was be- In the presented findings, there were disparities between cause it was not being given as much prominence as urban and rural women when it came to knowledge, atti- other diseases like malaria per their views on assessment tude and health seeking behavior towards breast cancer of public health information availed to them most of the and its screening. Whereas urban women identified con- times. An interview with a key informant from urban cerns such as partner related consensus, rural women setting revealed that if participants were given informa- mostly identified the lack of information, long distance to tion on breast cancer and its screening; there would be health facilities, long waiting lines in hospitals, financial rapid uptake of early breast cancer screening among constrains (lack of transport fares, high treatment/screening women. She said: costs) and lack of health professionals to perform needed screening tests as barriers to breast cancer screening. In the “In this community, if a woman does not know the recent past, gainful strides have been achieved in availing a importance of early breast cancer screening, they will more inclusive health insurance cover, increased adaptation not go for screening. But after they have been taught of treatment guidelines, expansion and upgrading of radio- on the importance, many of them flock to the screening therapy equipment across the country in addition to more rooms and get screened for cancer. An example is research opportunities [9, 21, 37]. However, even with cervical cancer. Most women have had a pap smear governments efforts, the uptake of these services remains done on them because there have been consistent low and/or delayed over time [21, 38]. For instance, out of seminars and campaigns on the importance of every seven women in Kenya, six have not been screened doing a pap.” for breast cancer [15, 16]. The disease strikes 1 in 9 women due to late diagnosis according to the Kenya National An urban participant in group 5 when asked what Cancer Control strategy and as observed on burden of measures can be put in to motivate women to go for breast cancer and contributing factors of high mortality early screening said: [23, 39–41]. Most women hardly seek professional medical attention untill symptomatic pointers are advanced [42]. It “If they gave us information on breast cancer, it would was observed in the FGDs while some urban women motivate me to go for screening.” opted to seeking treatment in health facilities when they Kisiangani et al. BMC Women's Health (2018) 18:81 Page 7 of 9 discovered that they had a lump in their breast, most rural rates are higher among those diagnosed with the complica- women and some urban women prefered to seek care tion [44]. The high death rate among rural women diag- from complementary and alternative medicine providers nosed could be attributed to their fear and perception or ignore the lump hoping it would clear off. about the disease (it would lead to further spread, death, Against the backdrop of improvement efforts, the and loss of their position in the society as women). The present findings still mirror earlier observations of low presented findings on perceived severity were comparable uptake and with socio-economic factors of health having to preceding assesesments [15, 16] despite the varied been implicated in influencing individuals and commu- geographical and cultural settings. nities’ health seeking behaviors [1, 43]. Further evidence that correspond to the present study points to lack of Conclusion awareness, insufficient financial resources, worry about Creating breast cancer awareness alongside clear guidelines examination discomfort, fear of finding cancer due to on accessing screening and treatment infrastructure is associated myths and stigma, and inability to establish critical. The messaging should aim at instilling hope and effective follow-up treatment [14, 15, 18, 20]. The eradicating the myths and misconseptions harboured about barriers reported by the rural participants in the current the disease. It was evident, a diagnosis of breast cancer/ study could be attributed to the fact that most rural lump with lack of clear course of expertise support, brings areas are usually characterized by low population density unpexpected confrontation with mortality; the fear, pain, and residents have poor access to health care than their cultural barriers, emotional and financial distress are very urban setting counterparts as earlier observed [44]. Fur- real. Without clear referral channels to enable those with thermore, according to WHO (2007) study on the social suspicious lumps or early stage disease to get prompt diag- determinants of health, lack of knowledge and awareness nosis and treatment, then well-meaning awareness will not to health is a great barrier in seeking health among necessarrily contribute to reducing morbidity and mortality. women as well as stigmatization associated with breast cancer, fear, and fear of rejection by marital partners as a Additional files result of being diagnosed with the disease [45].The Additional file 1: Interview guide for the focus group discussions and aspect underpins the need for family, partner involve- in-depth interviews (key informants) (DOCX 44 kb) ment and both gender targeted approaches in promoting Additional file 2: Map of the study areas. (DOCX 2073 kb) awareness which has been the effort to enhanced success Additional file 3: Perceived barriers to early breast cancer screening of other programmes like the fight against HIV [46]. uptake and treatment as mentioned by FGD participants. (DOCX 18 kb) Among the urban women, decision to visit a health facil- ity on the discovery they had breast cancer was influenced Abbreviations by their knowledge and information about breast cancer. BSE: Breast self-examinations; CBE: Clinical breast exams; DPHN: District Public Health Nurses; FGD: Focus group discussion; HBM: Health belief model; Women who are knowledgeable about breast cancer and IEC: Information, education and communications; KII: Key informant its risk factors are known to be more likely to comply with interview; NCDs: Non-communicable diseases such early detection behaviors than those who are not [47]. Acknowledgements Rural women decisions are influenced by lack of informa- The authors would like to thank the focus group and KII participants as well tion on breast cancer with one of the leading factors to late as the county and sub-county administrators for their time, help and feedback presentation being lack of awareness about benefits of early in the implementation phase of the project. detection of breast cancer as observed in varied setting and Availability of data and materials colloborated by the presented findings [48–51]. Conse- We have presented all our main data in the form of themes and tables. The quently, there are high indications that women have mis- datasets supporting the conclusions of this article are included within the article (and its Additional files). conceptions on breast cancer and its screening because they cannot access health information [12, 15]. This line of Authors’ contributions thought is reinforced by the Kenya Cancer Research and JK, CKW and PM conceptualized the manuscript and designed plan of Control National Stakeholder Meeting action points that analysis. JK, PM, JKC, EOA and CKW conducted the analysis and wrote the manuscript, which was later reviewed by all the authors. In addition, JK, JB, highlight: 1) Engaging community leaders and members to HM and CKW led the major population-based study that provided the data identify key drivers of stigma through Knowledge, Attitude, source for this paper. All authors read and approved the final manuscript. and Practice (KAP) studies, 2) Developing culturally appro- Ethics approval and consent to participate priate messages to address perceptions and knowledge The conduct and reporting presented in this paper adhered to the gaps, 3) Coordinating knowledge sharing about community consolidated criteria for reporting qualitative research (COREQ) guidelines education efforts and 4) Raising public awareness about [52]. Ethical approval to carry out the study was obtained from the Moi Teaching and Referral hospital Institutional Research and Ethics Committee cancer prevention and early detection, targeting 60% of the (IREC). Formal Approval Number: FAN: IREC 1058. Written informed consent population by 2018. Incidences of breast cancer have been was also obtained from each study participant. All aspects of the study were observed to be low among rural women however, death conducted in accordance with the approved protocol. Kisiangani et al. 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Determinants of breast cancer early detection for cues to expanded control and care: the lived experiences among women from Western Kenya

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Medicine & Public Health; Gynecology; Maternal and Child Health; Reproductive Medicine
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Abstract

Background: Estimately, 70–80% of cancer cases are diagnosed in late stages in Kenya with breast cancer being a common cause of mortality among women where late diagnosis is the major ubiquitous concern. Numerous studies have focused on epidemiological and health policy dynamics essentially underestimating the determining factors that shape people’s choices and cues to health care service uptake. The study sought to evaluate the knowledge, attitude and health seeking behavior towards breast cancer and its screening in a quest to explain why women present for prognosis and treatment when symptomatic pointers are in advanced stages, impeding primary prevention strategies. Methods: Eight focus groups (6–10 members per group) and four key informant interviews were conducted among adult participants from rural and urban settings. Sessions were audio-recorded and transcribed. A thematic analysis of the data was based on the concepts of the health belief model. Data analysis was conducted using NVIVO10. Results: Most women perceived breast cancer as a fatal disease and conveyed fear of having early screening. Rural women preferred self-prescribed medications and the use of alternative medicine for long periods before presenting for professional care on suspicion that the lump is cancerous. Accessibility to equipped health facilities, lack of information to establish effective follow-up treatment and low-income status were underscored as their major health seeking behavior barriers whereas, urban women identified marital status as their main barrier. Key informant interviews revealed that health communication programs emphasized more on communicable diseases. This could in part explain why there is a high rate of misconception and suspicion about breast cancer among rural and urban women in the study setting. Conclusions: Creating breast cancer awareness alongside clear guidelines on accessing screening and treatment infrastructure is critical. It was evident, a diagnosis of breast cancer or lump brings unexpected confrontation with mortality; fear, pain, cultural barriers, emotional and financial distress. Without clear referral channels to enable those with suspicious lumps or early stage disease to get prompt diagnosis and treatment, then well-meaning awareness will not necessarily contribute to reducing morbidity and mortality. Keywords: Breast cancer, Early breast cancer screening, Focused group discussions (FGD), Key informant interviews * Correspondence: khayekachris@yahoo.com School of Pharmaceutical Science and Technology (SPST), Health Science Platform, Tianjin University, 92 Weijin road, Nankai District, Tianjin 300072, People’s Republic of China African Population and Health Research Center (APHRC), P .O. Box 10787-00100, Nairobi, Kenya Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kisiangani et al. BMC Women's Health (2018) 18:81 Page 2 of 9 Background Methods Cancer is the third highest cause of mortality in Kenya after Study design infectious and cardiovascular diseases. Leading cancers are The qualitative research was conducted between November breast and cervical for women [1, 2]. Seventy to 80 % of 2013 and March 2014. A qualitative design using focus cancer cases are diagnosed in late stages. Like many other group discussion (FGD) and key informant interview (KII) Non-Communicable Diseases (NCDs) breast cancer methods was applied as an ideal approach to explore progresses slowly, degenerates to devastating disabilities perceived motivators and barriers to healthy behaviours and the management costs are high if not timely diagnosed [24]. The items in the FGD and KII were developed based and treated. There is better prognosis, greater chances of on the concepts of the health belief model [16, 25–29]. successful treatment and high survival rates when detected Interview guide for the focus group discussions and at early stages. Methods such as clinical breast exams in-depth interviews (key informants) are as provided (see (CBE), mammograms and breast self-examinations (BSE) Additional file 1). The concepts included; percieved severity have been used as main approaches [3, 4]. of breast cancer, perception of susceptibility to breast Health care access is considered a multidimensional con- cancer, perceived benefits of breast cancer early detection cept encompassing both financial and non-financial dimen- measures, perceived barriers to breast cancer early detec- sions [5, 6]. It has broadly been defined as the degree of fit tion measures, self-efficacy and cues to action. The concep- between a patient’s socioeconomic characteristics, the tual framework for the qualitative interview was adapted as health system, and health services organization [5, 6]. The earlier reported [30, 31]and is showninFig. 1.This five core components of access that have been outlined are: approach was selected because FGDs and KIIs can be acceptability, affordability, accessibility, accommodation, undertaken in naturalistic settings which may stimulate and availability [5–9]. In Kenya, tremendous gains have more openness and candor [32, 33]. Also the group inter- been made in the recent past on affordability, accommoda- action has the capability to elicit information and insights tion, and availability of cancer screening and treatment that are less accessible during individual interviews [34]. services whereas much more effort still needs to be put on Probing by the moderator allowed in depth exploration of accessibility and acceptability [8, 9]. Compelling findings on unanticipated issues as well as an opportunity to clarify and breast cancer in Kenya still show that most women are not enhance understanding of responses [33]. aware of signs and symptoms of breast cancer due to cul- tural diversity views and limited education and awareness Study setting and participants programs with a lag on clear referral channels information Kakamega is aCountyinWestern Kenyalying about30 empowerment [8, 10–14]. This considers the fact that, KM northofthe Equator. The countyhas apopulation of there are varied underlying information and awareness about 1.7 million (KNBS, 2010) with a population density factors among Kenyan women on early cancer screening of about 544 people per square kilometer and is Kenya’s and on why and under what conditions they would take second most populous county after Nairobi [35]. According action towards medical attention for prevention or early to the 2009 census, 15.2% of the population lives in urban screening and treatment [4, 15, 16]. areas. Of the approximately 1.7 million people,48% are male As studies shed more understandings on the the risks and 52% female. The population is relatively poor with a and benefits of early breast cancer screening, indepth povertyrateof53% [35]. The main health facilities in the understanding of women perceived risk and barriers have county and its environs are: Kakamega General Hospital, become integral [13, 17, 18]. The insights can help influ- Central Maternity and Nursing Home, Butere district ence women choice of approaching early screening and hospital, Malava district hospital, Mumias district hospital, treatment options or risk-reduction strategies and effective Matungu, Manyala and Navakholo sub-district hospitals, follow-up treatment [17–19] in a targeted approach that Kima Mission Hospital and Kimilili District Hospital. resonate with their gendered socio-cultural role; their The researcher divided the 12 constituencies into two perceived susceptibility, severity, benefits and perceived groups; urban and rural using Kakamega First County health needs [6, 20]. The study thus generates and Development Plan, 2013. Map of the study areas, enhances the pool of evidence that would aid inform the Kakamega couty constituencies and study locations (see development of local cancer information, education and Additional file 2). Urban groups include: Mumias West, communications (IEC) tailored for communities in Kenya Lurambi, Shinyalu, Mumias East and Butere whereas incorporating approaches that fully engage the target pop- Rural groups comprise: Matungu, Khwisero, Malava, ulations [21]. As a result, potentially promote optimization Ikolomani, Navakholo, Lugari and Likuyani. Two con- of the existing and upcoming national health systems for stitntuencies for rural settings (Ikolomani and Likuyani) cancer management under the vision 2030 and beyond as and urban settings(Mumias West and Lurambi) respect- envisaged under the cancer awareness, community en- ively were randomly selected. Eligible participants were gagement plan [6, 14, 21–23]. selected using a purposive sampling method. Thus, for Kisiangani et al. BMC Women's Health (2018) 18:81 Page 3 of 9 Fig. 1 Conceptual framework for the qualitative interview. Adapted from [30, 31] the FGDs, homogenity on particular characteristics was where necessary. Information from KII (the first one to considered; (in this case it was for gender, age and rural be conducted) helped inform some of the questions to or urban) and recruited from the communities of the ask in FGD. Thus, gaining further understanding on the randomly selected constituencies. Convenience sampling validity of DPHN perspective in resonance to the (number of locations and sub locations per consitutency population they attend to and considering they often for more objective representation) was utilized for selec- provide inputs in appraising government health sector tion of the FGDs members by the researchers with the operational guidelines and policies which have a direct help of local leaders (chiefs and sub-chiefs) through their bearing on the populations they serve. Focus groups documented community governance records. Thus, the lasted between 43 to 65 min. Rural focus groups were FGDs were conducted in two groups: young women of conducted in Swahili while discussions with urban age group 18–35 and older women of age group 36–60 women took place in Swahili and English. The items in emanating from either urban or rural concsitituency. FGD interviews were initially formulated in English then Hence, 72 participants all above 18 years were inter- translated into Swahili for the use in the different study viewed, and comprised of four key informants and 68 locations. Data collected in Swahili versions were trans- members of 8 FGDs with between 6 and 10 participants lated back to English to ensure consistitency with the per FGD. Two (2) focus groups were drawn from each data collected in English versions. The five-phase cycle constituency. For each set of 2 groups, 1 FGD consti- of compiling, disassembling, re-assembling (and array- tuted women of age 18–35, and another of women of ing), interpreting and concluding were used to process age 36–60. One (1) key informant was drawn from each the data as earlier described [36]. constituency. Key Informants were the four District Public Health Nurses (DPHN) that were from the four constituencies where the FGDs were done. The DPHN Data analysis were considered because, they interact with a significant All the data from the KIIs and FGDs were then uploaded proportion of women in these communities and there- to the Computer Assisted Qualitative Data Analysis Soft- fore considered to be more knowledgeable of what the ware (CAQDAS) QSR Nvivo10 for windows for manage- women face in obtaining early breast cancer screening. ment and analysis. Coding was done as earlier described Consented participants were allocated to a focus group [36] with level 1 to level 3 coding with the following session or Key informant interviews (KII) based on the major emerging categories from the level three coding: respective eligibility cirteria. health seeking behavior of breast cancer and its screen- ing, knowledge of breast cancer and its screening, atti- Data collection tude towards breast cancer and its screening and breast The items in the focus group discussion interviews and health promotional strategies. Comparisons between the key informant interviews were developed based on the four groups; urban rural, 18–35 year old women and concepts of the health belief model (as above-mentioned those aged 36–60 years were made as categories and detailed). The concepts were pretested with small emerged. Findings were reported per the themes/topics groups outside the target study area and revisions made that emerged. Kisiangani et al. BMC Women's Health (2018) 18:81 Page 4 of 9 Results their women to go for cancer screening as it is a disease Findings from the focus group discussions and key inform- that is associated with terminal health complications ant interviews are presented per the main categories from equating it to be even more worse than HIV/AIDS and level 3 coding that emerged. getting to know makes it even more hard to live with the new reality. Contrary, rural women (up to 75% of rural Category one: Health seeking behavior of breast cancer participants) identified long distance to health facility, lack and its screening of information on breast cancer and its screening and Sixty-eight women aged 18–60 years (age: 18–35: 36 and low-income status as major health seeking behavior bar- 36–60: 32) from the selected rural and urban constituen- riers. An older woman from rural group 4 said: cies of Kakamega county Kenya participated in eight focus groups (average 8.5 participants per group). Of these 63 “Ignorance and lack of information on the importance (92.6%) were Christians and 5 (7.4%) were Muslims. of cancer screening hinders women from seeking early Participants were predominantly married (72.1%). The breast cancer screening”. educational level of the respondents varied considerably; 45.6% had primary education, 35.3% secondary, 11.8% A younger woman from rural group 1, said: middle level college training and 2.9% university degree while the rest had no formal schooling. There were 32 “The long distance to the cancer facility would cost women from the rural setting and 36 urban. The average a lot of transport fare that I cannot afford and this family size was 6 persons, with an average of 4 children makes it difficult for me.” per woman. All working women had government medical cover, the National Health Insurance Fund (NHIF) An interview with Key informant revealed that the through their jobs, granting coverage for health service health centres and hospitals do not have enough nurses to use at governmental facilities for themselves and their perform regular breast cancer screening. She narrated: dependents. Despite having NHIF cover, the women expressed a generalized preference for private health care “The number of staff in the hospitals should be providers. They however explained that, their choice to increased. Sometimes you will find there is only one use public rather than private services was often mediated nurse who has to do everything in a hospital. When by a series of social, economic, and geographical consider- a woman comes in for a BCS, the nurse is most likely ations. None of the women had private health insurance to attend to the patients whose lives are at risk first. cover instead self-help savings and credit groups, com- There should be devolution. The number of staff monly known as chamas were common source of building should be increased.” financial capacity and borrowing among the women. The vast majority of women rated their health status as good. Through indepth discussions it was evident cultural There were disparities between the urban and rural religion orientation was a contributing barrier among when it came to health seeking behavior barriers (see rural women compared to their urban counterparts. A Additional file 3). Most urban women (from all the 4 rural participant from rural group 3 said; urban FGDs) identified marital status as their major barrier to early breast cancer screening. Specifically, “Some women go to churches that believe in prayers young-urban women explained that married women for healing, the churches do not allow their followers have to consult and at times get not only advice but also to go to the hospital. Such women do not go for breast permission from their husbands before seeking any cancer screening.” medical help or undertaking social commitments that has an impact on their health. An urban woman from The study further revealed that most women are skeptical group 7 to symbolically contextualize the challenge of having early breast cancer screening as attributed to fear depth narrated: of getting a positive breast cancer diagnosis; stigmatization associated with it and breast cancer related cultural beliefs “Some men do not allow their women to go to the alongside misconceptions as well as the, what next? doubts. hospital. Most men do not even allow their women The action taken when a woman realized she had a breast to go out of the homestead and ‘fetch water for lump was influenced by the community perception of the domestic use’, how then will they even allow origin of the disease for the older urban participants, con- women to go for cancer screening at the hospital?” ventional practices and beliefs for most rural participants and level of knowledge by younger-rural women. Most They went further to explain that as the head of the urban women described the community perception and home, some husbands would have difficulties in allowing association of breast cancer to promiscuity, infidelity, and Kisiangani et al. BMC Women's Health (2018) 18:81 Page 5 of 9 equating it to HIV/AIDS thus hindering women who sus- “I know they are cells that multiply in the breast pected a lump in their breast was cancerous from seeking leading to death.” early treatment in hospitals. An older woman from the urban group 8 narrated: Specifically, young urban participants seemed more knowledgeable about lifestyle issues that predispose indi- “If a woman is known to be sleeping around with viduals to breast cancer. They mentioned smoking, too many men, and she discovers that she has breast much sugar and salt in food, use of bleaching pills and cancer, she will prefer not to go and seek treatment self-medicated pills. A woman in urban group 7 said: because she is afraid that she might go to the hospital, get tested for HIV and told that she has AIDS.” “I know that it is brought about by smoking and using a lot of fat in your food.” Rural women on the other hand preferred using herbal remedies, self-medicating with painkillers or going to trad- Other misconceptions across the women included being itional medicine men for complementary and alternative born with “risky bugs” in their breasts, breast cancer being remedy when they suspected they had a cancerous lump a consequence of having HIV and prostitution as well as in their breast. A woman from rural group 3 said: surgery of the breast being associated with breast cancer status and death. “Women believe it is a sore, so we take traditional herbs called “miyeka”.” Category three: Attitudes of women toward breast cancer and its screening We also established that younger-rural participants and Most women were concerned of breast cancer and were older participants were not aware or clear of simple overwhelmingly convinced that it is a serious terminal methods such as breast self-examination or where they disease with no cure. Terms such as ‘deadly and death’ could get early breast-screening services. Several older were commonly used in the description of breast cancer. participants asked to be taught how to detect a lump in A participant in rural group 2 said: their breast while younger women explained that they were not confident on performing breast self-examination “Breast cancer is a death sentence.” on themselves. A young participant explained in frustra- tion how nurses instructed them to palpate their breast Another participant in rural group 1 said: but she did not understand how palpation was done or what the nurses meant by palpate. When asked how to “I understand that it has no cure. It is an incurable check for lumps in their breast, a participant from urban disease.” group 8 said: Several participants also described the perceived serious- “We do not know. You should teach us on how one ness of the disease as extremely dangerous and incurable. A knows that they have breast cancer.” young woman in urban group 5 stated: This is despite the fact that health centres in Kakamega “The women in the community believe that breast County schedule a day in a month for breast health edu- cancer is a disease that does not have a cure and cation. A key informant from a rural group explained so will not bother to go to the hospital.” that most facilities in the county conduct breast screen- ing at facility level once a month. However, she also Participants were also afraid of CBE. A participant from added that it was likely that women did not know that urban group 8 narrated: they could access such services for free due to lack of information. “I do not think going for breast cancer screening is a necessity. One woman that I know went for breast cancer screening and was told that she had it and Category two: Knowledge of breast cancer and its that her breast had to be removed... When her breast screening was cut, the cancer spread throughout her body and Younger participants seemed to have a better comprehen- following that, I and many of my friends who knew sion of breast cancer, its early manifestations, early breast her can’t go to the hospital.” cancer screening and predispositions’ to the disease com- pared to older participants. A participant from rural group Some urban participants seemed well aware of the 1 defined breast cancer as: benefits of early breast cancer screening. They noted that Kisiangani et al. BMC Women's Health (2018) 18:81 Page 6 of 9 knowing their breast cancer status early would result to The participants also asked for free and regular breast the early treatment of the disease and this would increase cancer screening services to be made available not only in the chances of survival. They also explained how early mother-child health clinics but also in the overall hospitals screening uptake reduces the high cost of treatment of the services. When the women were asked on the best channel disease if it is detected early. A woman from urban group of communication of information on breast cancer and its 6said: screening, urban participants suggested the use of media, and mother-child health clinics. Most young participants “If I am found with cancer at an early stage, it means suggested use of community health workers (CHW), social that I will not spend much on the treatment of the media and text messages as the best avenues for the com- disease. It will be cheaper for me.” munication of information. Rural participants suggested the use of community health workers. A rural participant said: Despite this knowledge among some of the partici- pants, they were still sceptical of having early breast can- “Through seminars- they should take CHW’son cer screening as it would lead to psychological stress, seminars, and when they come they should educate depression and even early death unlike when they were the community on breast cancer by doing door to not aware. door education.” Category four: Breast health promotion strategies Older women suggested use of door to door education, Most of the participants had very limited knowledge of churches, village meetings (barazas) and village chief’sas breast health awareness programs. Participants could the best channel for communication of information on only mention programs aimed at communicable diseases breast cancer and its screening. Key informant 2 suggested: (Malaria and HIV) awareness creation. Participants from rural group 2 said: “Verbal health education- use of wall charts, the mass media, chief barazas and use community leaders “There is no much emphasis on breast cancer (church leaders and chiefs to talk to them).” awareness campaigns.” The participants pointed out the reason why they do Discussion not have much information on breast cancer was be- In the presented findings, there were disparities between cause it was not being given as much prominence as urban and rural women when it came to knowledge, atti- other diseases like malaria per their views on assessment tude and health seeking behavior towards breast cancer of public health information availed to them most of the and its screening. Whereas urban women identified con- times. An interview with a key informant from urban cerns such as partner related consensus, rural women setting revealed that if participants were given informa- mostly identified the lack of information, long distance to tion on breast cancer and its screening; there would be health facilities, long waiting lines in hospitals, financial rapid uptake of early breast cancer screening among constrains (lack of transport fares, high treatment/screening women. She said: costs) and lack of health professionals to perform needed screening tests as barriers to breast cancer screening. In the “In this community, if a woman does not know the recent past, gainful strides have been achieved in availing a importance of early breast cancer screening, they will more inclusive health insurance cover, increased adaptation not go for screening. But after they have been taught of treatment guidelines, expansion and upgrading of radio- on the importance, many of them flock to the screening therapy equipment across the country in addition to more rooms and get screened for cancer. An example is research opportunities [9, 21, 37]. However, even with cervical cancer. Most women have had a pap smear governments efforts, the uptake of these services remains done on them because there have been consistent low and/or delayed over time [21, 38]. For instance, out of seminars and campaigns on the importance of every seven women in Kenya, six have not been screened doing a pap.” for breast cancer [15, 16]. The disease strikes 1 in 9 women due to late diagnosis according to the Kenya National An urban participant in group 5 when asked what Cancer Control strategy and as observed on burden of measures can be put in to motivate women to go for breast cancer and contributing factors of high mortality early screening said: [23, 39–41]. Most women hardly seek professional medical attention untill symptomatic pointers are advanced [42]. It “If they gave us information on breast cancer, it would was observed in the FGDs while some urban women motivate me to go for screening.” opted to seeking treatment in health facilities when they Kisiangani et al. BMC Women's Health (2018) 18:81 Page 7 of 9 discovered that they had a lump in their breast, most rural rates are higher among those diagnosed with the complica- women and some urban women prefered to seek care tion [44]. The high death rate among rural women diag- from complementary and alternative medicine providers nosed could be attributed to their fear and perception or ignore the lump hoping it would clear off. about the disease (it would lead to further spread, death, Against the backdrop of improvement efforts, the and loss of their position in the society as women). The present findings still mirror earlier observations of low presented findings on perceived severity were comparable uptake and with socio-economic factors of health having to preceding assesesments [15, 16] despite the varied been implicated in influencing individuals and commu- geographical and cultural settings. nities’ health seeking behaviors [1, 43]. Further evidence that correspond to the present study points to lack of Conclusion awareness, insufficient financial resources, worry about Creating breast cancer awareness alongside clear guidelines examination discomfort, fear of finding cancer due to on accessing screening and treatment infrastructure is associated myths and stigma, and inability to establish critical. The messaging should aim at instilling hope and effective follow-up treatment [14, 15, 18, 20]. The eradicating the myths and misconseptions harboured about barriers reported by the rural participants in the current the disease. It was evident, a diagnosis of breast cancer/ study could be attributed to the fact that most rural lump with lack of clear course of expertise support, brings areas are usually characterized by low population density unpexpected confrontation with mortality; the fear, pain, and residents have poor access to health care than their cultural barriers, emotional and financial distress are very urban setting counterparts as earlier observed [44]. Fur- real. Without clear referral channels to enable those with thermore, according to WHO (2007) study on the social suspicious lumps or early stage disease to get prompt diag- determinants of health, lack of knowledge and awareness nosis and treatment, then well-meaning awareness will not to health is a great barrier in seeking health among necessarrily contribute to reducing morbidity and mortality. women as well as stigmatization associated with breast cancer, fear, and fear of rejection by marital partners as a Additional files result of being diagnosed with the disease [45].The Additional file 1: Interview guide for the focus group discussions and aspect underpins the need for family, partner involve- in-depth interviews (key informants) (DOCX 44 kb) ment and both gender targeted approaches in promoting Additional file 2: Map of the study areas. (DOCX 2073 kb) awareness which has been the effort to enhanced success Additional file 3: Perceived barriers to early breast cancer screening of other programmes like the fight against HIV [46]. uptake and treatment as mentioned by FGD participants. (DOCX 18 kb) Among the urban women, decision to visit a health facil- ity on the discovery they had breast cancer was influenced Abbreviations by their knowledge and information about breast cancer. BSE: Breast self-examinations; CBE: Clinical breast exams; DPHN: District Public Health Nurses; FGD: Focus group discussion; HBM: Health belief model; Women who are knowledgeable about breast cancer and IEC: Information, education and communications; KII: Key informant its risk factors are known to be more likely to comply with interview; NCDs: Non-communicable diseases such early detection behaviors than those who are not [47]. Acknowledgements Rural women decisions are influenced by lack of informa- The authors would like to thank the focus group and KII participants as well tion on breast cancer with one of the leading factors to late as the county and sub-county administrators for their time, help and feedback presentation being lack of awareness about benefits of early in the implementation phase of the project. detection of breast cancer as observed in varied setting and Availability of data and materials colloborated by the presented findings [48–51]. Conse- We have presented all our main data in the form of themes and tables. The quently, there are high indications that women have mis- datasets supporting the conclusions of this article are included within the article (and its Additional files). conceptions on breast cancer and its screening because they cannot access health information [12, 15]. This line of Authors’ contributions thought is reinforced by the Kenya Cancer Research and JK, CKW and PM conceptualized the manuscript and designed plan of Control National Stakeholder Meeting action points that analysis. JK, PM, JKC, EOA and CKW conducted the analysis and wrote the manuscript, which was later reviewed by all the authors. In addition, JK, JB, highlight: 1) Engaging community leaders and members to HM and CKW led the major population-based study that provided the data identify key drivers of stigma through Knowledge, Attitude, source for this paper. All authors read and approved the final manuscript. and Practice (KAP) studies, 2) Developing culturally appro- Ethics approval and consent to participate priate messages to address perceptions and knowledge The conduct and reporting presented in this paper adhered to the gaps, 3) Coordinating knowledge sharing about community consolidated criteria for reporting qualitative research (COREQ) guidelines education efforts and 4) Raising public awareness about [52]. Ethical approval to carry out the study was obtained from the Moi Teaching and Referral hospital Institutional Research and Ethics Committee cancer prevention and early detection, targeting 60% of the (IREC). Formal Approval Number: FAN: IREC 1058. Written informed consent population by 2018. Incidences of breast cancer have been was also obtained from each study participant. All aspects of the study were observed to be low among rural women however, death conducted in accordance with the approved protocol. Kisiangani et al. 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BMC Women's HealthSpringer Journals

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