By: Lauren Elreda, Research Manager
Breast cancer awareness is critical to reducing mortality from breast cancer around the world. Awareness empowers individuals to understand the importance of regular screenings, risk factors, early signs and symptoms to look out for, and prompt medical attention if symptoms arise. While considerable strides have been made in promoting global breast cancer awareness, substantial inequities remain both between and within countries, especially low- and middle-income countries (“LMICs”).
As part of a larger multi-national public health research project in Fall of 2022, ORB International measured awareness of 15 common cancers in five LMICs: Nigeria, Ghana, Côte d’Ivoire, Nepal, and Indonesia. Results from nationally representative surveys, as well as in-depth interviews with key public health stakeholders (community health workers, civil servants, and community and religious leaders), provide a glimpse into the current state of awareness across these five countries, and insights into economic, societal, and cultural factors that contribute to inequities in awareness.
Revealed Inequities
ORB’s surveys revealed that, although awareness of breast cancer is generally higher than that of other cancers, awareness levels in some countries are still very low. Awareness of breast cancer ranked highest among cancers in all countries except Nepal. Despite this, only about a third of adults reported knowing “a lot” or “a fair amount” about breast cancer in Indonesia (39%), Nepal (34%), and Côte d’Ivoire (33%). This contrasts sharply with Nigeria and Ghana, where self-reported knowledge was 63% and 52%, respectively. These numbers highlight that there is not only still much work to be done to raise breast cancer awareness globally, but also to overcome disparities in awareness between countries.
ORB’s data also reveal noteworthy disparities in awareness within countries, across different demographics:
- Respondents under 35 reported being significantly less informed about breast cancer than older respondents in Nigeria, Ghana, and Côte d’Ivoire.
- Men reported significantly less awareness of breast cancer than did women in Nigeria, Ghana, Indonesia, and Nepal.
- Respondents with less education, of lower socioeconomic status, and living in rural areas, reported significantly less breast cancer awareness in Indonesia and Nepal.
These findings raise important questions about why awareness levels differ so substantially by demographics, and why more so in some countries than others. Indeed, an important step toward reducing health disparities in general – both within and between countries – is to better understand the factors that contribute to inequities in awareness and in turn, lead to inequities in incidence and mortality rates. For this reason, we interviewed key stakeholders about the challenges around dissemination and uptake of important global public health recommendations. They point to four key barriers (consistent with prior research) that hinder awareness and early detection in many LMICs and can lead to inequitable outcomes.
ORB data collector in the field
1. Limited resources for public health campaigns
Breast cancer awareness and screening campaigns can be highly effective at raising awareness and improving early detection on a national scale and at reaching those most in need of the information, such as those in more remote rural areas or with less education1 2. Unfortunately, LMICs often lack the financial resources to implement the type of nation-wide campaigns needed to spread awareness, which (as the key stakeholders we interviewed emphasized) typically require multi-pronged communication approaches, including elements such as TV advertisements, radio jingles, community gatherings, and door-to-door campaigns3. For instance, stakeholders in Ghana described funding needed for the organization and delivery of community gatherings (“durbars”) to disseminate public health recommendations:
___________________________
“Some of the communities are far and when you want to talk about you need to organize a durbar and organizing a durbar you need money to let people know that you are organizing durbar. They need food and other things, so when it comes to creating awareness, funding is a barrier.”
Female Health Worker in Ghana
___________________________
Most LMICs rely on financial assistance from higher income countries and international organizations (such as the WHO) in order to make implementation of public health initiatives feasible. Clearly, continued work is needed to ensure all countries have the funds needed to carry out breast cancer awareness and screening initiatives that effectively reach all segments of their populations.
2. Government prioritization
Raising breast cancer awareness on a national level requires national governments to prioritize the issue and commit time and resources to awareness initiatives. Across the LMICs from which we collected data, key stakeholders discussed common barriers to government prioritization, including lack of awareness among government decision-makers about many public health issues, as well as too many other competing priorities and consequently, a tendency for public health issues (especially related to women’s health) to fall low on the list of priorities:
___________________________
“Our country is a developing country that falls under the category of undeveloped country. Since the people in this country frequently struggle to survive, it is usual for health to fall low on their list of priorities. Politicians . . . lack knowledge about public health and how to deal with the general public’s health issues.”
Male Health Worker in Nepal
___________________________
While financial resources substantially limit the ability of many LMICs to prioritize breast cancer awareness and screening initiatives, these initiatives are often made possible with the assistance of donor countries and organizations. Yet acquiring this type of assistance often requires the country’s national government to seek it out or apply for it, and national governments are often responsible for following through on the implementation of those initiatives even once financial assistance is granted. Thus, these barriers to prioritization are important to bear in mind as we consider ways to continue raising awareness and reducing global inequities.
3. Limited access to and institutional capacity of healthcare services
Also related to resource limitations, access to healthcare services, including breast cancer screening and treatment services, is limited in many LMICs. Key stakeholders shared numerous examples of access limitations that could hinder both awareness and early detection, especially for those in rural areas. For instance, insufficient road networks and an overall shortage of healthcare facilities pose significant challenges to geographical accessibility for many rural residents; and many health facilities, especially in rural areas, lack important equipment (such as mammography equipment) and are poorly maintained:
___________________________
“People from urban areas can readily access the hospitals because they are close by. They can share concerns regarding their problems. People in remote areas must travel a long distance to reach healthcare facilities.”
Female Community Leader in Nepal
___________________________
Further exacerbating the issue, health facilities are often underemployed, lacking enough staff to offer sufficient services to their communities, and often underpaying those who are employed. A health worker elaborated on this challenge:
___________________________
“Let us have adequate human resources for health. When I say adequate human resources for health, I don’t mean the underemployed staff—you cannot employ staff on an employed basis and expect them to do their best. When I say underemployed, I mean a facility that’s required to have eight, and you now employ four. Another example of underemployment is that you need six, you employ six, but they are underpaid, how can you expect this group of people to do their best, to achieve your desired goal?”
-Male Health Worker in Nigeria-
___________________________
When individuals lack access to regular, quality healthcare, they miss out on important recommendations from health professionals, as well as health services such as breast cancer screening that should be part of routine care. As global health advocates continue to work toward reducing incidence and mortality from breast cancer, healthcare infrastructure and institutional capacity in many LMICs should be an important area of focus, especially for reaching those in rural regions.
Nurses outside of health facility
4. Cultural factors
In addition to the resource related factors, it is also important to understand the cultural factors that can complicate attempts to increase awareness and early detection within each country, so that key public health stakeholders can design culturally sensitive awareness campaigns. Here we share just a couple examples of the types of cultural factors discussed by stakeholders across the 5 LMICs, although the specifics and relevance of each differed by country, and of course do not speak to what the most relevant factors may be in other LMICs:
Cultural Taboos. In some cultures, discussing diseases related to specific body parts – especially those associated with women’s femininity or sexuality – is considered taboo. Thus, in cultures where breasts are sexualized, public promotion of breast cancer screening and awareness can be met with resistance. Moreover, shame may hinder even private self-exams or discussion of breast-related health concerns with one’s friends, family, or doctor 4 5. Indeed, stakeholders in Nepal shared that topics perceived as being related to sex and especially women’s sexual health are highly taboo, and that women often travel to clinics far from their homes to avoid anybody finding out that they sought healthcare related to private or sexualized body parts:
___________________________
“Since they are ashamed to have a checkup in their neighborhood, they go elsewhere. They do not frequently visit our clinical perspective because of this.”
-Male Health Worker in Nepal-
___________________________
Religious and traditional beliefs. Religious or traditional beliefs can also hinder awareness or adoption of certain public health recommendations in particular communities. For instance, key stakeholders in Côte d’Ivoire shared that many Ivoirians rely primarily on traditional medicine and largely distrust health recommendations originating from modern or “Western” medicine, in part rooted in prior negative experiences6. Conversely, key stakeholders in Nigeria explained that in certain communities, religious leaders promote beliefs that make members of their congregations resistant to medical intervention in general: e.g., the belief that all healing must be done by God, and thus that any form of medical intervention is forbidden (consequently, rendering screening unnecessary). Key stakeholders in Nigeria also explained that information sharing in traditional communities often comes from the elders of the tribe or community, influencing the information that reaches the members of those communities.
Those working to increase awareness and early detection must recognize the role that these cultural factors play in individuals’ health decisions and how they may impact receptivity to messaging about breast cancer awareness in particular contexts.
Looking Forward
The landscape of global breast cancer awareness reveals both progress and persistent challenges. While some countries have made significant strides in raising awareness, substantial inequities persist within and between nations. Understanding and addressing these disparities is essential for reducing the burden of breast cancer worldwide. The findings from our research highlight the complex and multifaceted nature of these inequities, but also provide reasons for optimism and help highlight some key ways forward:
- Funding & Advocacy: As highlighted above, limited financial resources are at the root of many of the global inequities in breast cancer awareness, incidence, and mortality rates. Those working in this space must continue to advocate for allocation of funds to help LMICs overcome the key financial barriers to awareness and early detection, including funding for awareness and screening initiatives, and funds to help build the infrastructure and institutional capacity of healthcare systems in LMICs.
- Cultural Sensitivity: Communication approaches must be tailored to each country or context to ensure they are culturally sensitive, and that they will be effective within a particular local context. To that end, it is critical for outside organizations looking to raise awareness to collaborate with local experts to develop effective localized communication strategies.
- Engage Trusted Opinion Leaders: Where cultural or religious beliefs may hinder awareness and early detection, it is important to engage and involve the community’s most trusted opinion leaders (e.g., religious leaders, tribe elders) in awareness and screening campaigns. Public support from these figures can help gain trust and buy-in among those in their communities.
- Targeted, Localized Programs: As noted earlier, Nigeria exhibited high breast cancer awareness, with minimal disparities by urbanity, education, or socioeconomic status. While our single data point precludes us from identifying the causal factors that may explain this, it is worth noting that Nigeria has received significant international aid and programming – including for women’s health-related initiatives – often directed at rural communities 7 8. Our findings may be a positive sign of the effectiveness of targeted local programs at reaching marginalized populations
As Breast Cancer Awareness Month comes to a close, let us use this opportunity to not only spread knowledge about the importance of early detection and treatment but also to continue to advocate for the necessary efforts at local, national, and global levels. By addressing these inequities head-on, we can work towards a future where every individual has access to the information and resources needed for prevention and early intervention.
___________________________
1 Effectiveness of breast cancer campaigns in South Asia | Discover Health Systems (springer.com)
2 Review: The Effectivity of Awareness Campaigns of Breast Cancer from 2007 – 2011 in Increasing the Survival Rates of Breast Cancer Patients in Malaysia | USIM Research Repository System
3 ‘Learn from the lessons and don’t forget them’: identifying transferable lessons for COVID-19 from meningitis A, yellow fever and Ebola virus disease vaccination campaigns | BMJ Global Health
4 Factors Affecting Delayed Presentation and Diagnosis of Breast Cancer in Asian Developing Countries Women: A Systematic Review – PMC (nih.gov)
5 Breast cancer: The Asian survivors tackling taboo in the community – BBC News
6 Schneider, W. H., & Drucker, E. (2006). Blood transfusions in the early years of AIDS in sub-Saharan Africa. American journal of public health, 96(6), 984–994.
7 Nigeria Success Story – Saving Lives in Eastern Borno (usaid.gov)