2Directorate General of Health Services, Dhaka, Bangladesh
3Center for Disease Control, Directorate General of Health Services, Dhaka, Bangladesh
4National Medical College, Dhaka, Bangladesh
5ZH Sikder Women′s Medical College, Dhaka, Bangladesh
Perception on breast cancer influences the help seeking pattern of breast cancer patients. Negative perception causes delay in help seeking. Outcome or survival rate of breast cancer has a relation on perception. A cross sectional study was done during July 2015-June 2016, to assess the perception on breast cancer and to find out the help seeking pattern and extent of help seeking time among breast cancer patients. A total of 200 patients were selected following the convenient method of sampling from National Institute of Cancer Research and Hospital, Dhaka. Face to face interviews were taken from the diagnosed breast cancer patients admitted in the hospital. Forty five percent patients were illiterate and 83% were house wife. The mean age was 42 and mean monthly family income was around 9000 taka. Two thirds of the respondents were present with locally advance stage (stage III) and three fourth of the patients identified the lump as 1st symptom. Four of 10 patients first sought help to homeopathy for their cancer diagnosis and treatment. Mean help seeking time was 11 months. Nine out of 10 patients were agreed with the statement, 'I was healthy'. Maximum respondents (81.0%) agreed with the statement, 'wait and see what would be happened'. Results showed that there was a relationship between delay help seeking and the statement of perception. There were significant associations between the perception on expensive treatment, perception on 'I am healthy', perception on 'lump related with menstruation', perception on 'wait and see what would be happened', perception on 'feared to do operation, it may cause death' and perception on family income and the delay in help seeking. Along with perception on breast cancer use of alternative medicine, lack of social support, health care delivery system, economic factor etc. influence the pattern and delay in help seeking. Further to the existing efforts to correct the perception for early diagnosis and treatment to overcome this problem is suggested.
Keywords: Breast cancer, Perception, help seeking time, Help seeking practice
Cancer is predicted to be an increasingly important cause of morbidity and mortality in Bangladesh in the next few decades.1 As a result of increased life expectancies, globalization, and life style changes.2 demographic transition3 the incidence of breast cancer has been consistently increased globally.4 Each year, breast cancer is newly diagnosed in more than 1 million women worldwide and more than 400,000 women die from it.5,6 The decision to seek help is influenced by perception on the disease.7 Negative perceptions cause delay in medical help seeking of breast cancer patients. Perceptions depend on high degree of religious, cultural and social diversity. In South East Asian Region, it has a unique socio-cultural environment which influences people′s perceptions, attitudes, and behaviors in daily life.8 They also held more negative perception about breast cancer and its treatment.9 They are more likely to believe that their symptom is harmless and does not require action.10 The majority of patients perceived medical treatment of cancer involving frightening medical procedures, particularly surgery. For that reason, disease is diagnosed at advanced stage. The treatment of advanced stages of breast cancer is generally more expensive than treatment in earlier stages.11 Bangladesh has low level of public awareness of importance of early diagnosis and treatment. Breast cancer mostly has a superficial presentation by lump for that increase awareness, knowledge and early detection of breast cancer can be diagnosed easily. By early detection survival rate will be increased. Delay help seeking is likely to affect prognosis and survival of patients. Due to metastasis and its complications 90% of breast cancer patients died. There is an inverse association between delay and survival times, 1/3 of the mortalities can be avoided by early diagnosis and treatment.12 This premature death or disability causes social, economical or disability burden to the nation. By identifying responsible factors, interventions can be given. Delay seeking medical help and their perceptions on breast cancer is one of the burning issues among breast cancer patients. To achieve management success in breast cancer need to provide correct identification of potential breast cancer symptoms among target populations. Correct identification is an important in predictor to seek medical care.10 In Bangladesh, regarding this topic, there may be some information available but major issues are not covered. Data are very urgently needed for decision making. It is an upcoming priority problem and priority health need. This information will be helpful for further research and in policy implication. The objectives of the study was to assess the perception on breast cancer and to find out the help seeking pattern and extent of help seeking time among breast cancer patients. Perception may be defined as the way of thinking about or understand something by breast cancer patients and delay included both patients delay and providers delay. Seeking help means to seek medical help from health care service provider.
A cross sectional study was done to assess the perception on breast cancer and to find out the help seeking pattern and extent of help seeking time among breast cancer patients. A total of 200 samples were selected following the convenient method of sampling at National Institute of Cancer Research and Hospital, Dhaka from July 2015-June 2016. Data collection period was 3 months. Each week there was a five working days. It was about 60 working days. To interview each questionnaire, it was taken 45- 60 minutes. For that, each day maximum 3 questionnaires were interviewed. For that the sample size was 60 X 3 = 180, finally 200 samples were taken. Face to face interview was taken from diagnosed breast cancer patients admitted in selected hospital by pretested semi structured questionnaire. Ethical Clearance was taken from IRB of NIPSOM (NIPSOM/ IRB/ 2016/ 18) and written permission was taken from hospital authority before taking interviews (NICRH/ Ethics/ 2016/204-5). Patients of breast cancer fulfilling the selection criteria were enrolled. To avoid recall bias newly diagnosed primary carcinoma patients were selected. Perspectives of the study were explained to the respondents and informed consent was taken from each respondent. The questionnaire included socio demographic questions of patients, question about current treatment status of the respondents, medical help seeking time of treatment, perception about cancer symptom and treatment and reasons for negative perception, clinical information such as stage of disease, type of surgical management was obtained from a review of medical records. Perception questionnaire was prepared by reviewing literatures of qualitative study which was done in South East Asian Region7,13,14,15 and from various models.16,17 Analysis of data was done by "Statistical Package for Social Science″ (SPSS) program (21 version). Descriptive statistics like frequency distribution, mean, median, mode, range, standard deviation etc. were calculated by SPSS program. Association was seen between help seeking time and other variables by Pearson′s Chi-square (X2) 2x2 table at p<0.05 level of significance.
Among 200 respondents, maximum 90 (45.0%) patients were illiterate and house wife 166 (83.0%) and mean age was 42, 85 (42.5%) respondents monthly family income was (6000-10000) taka, and 149 (74.5%) patients identify the lump as 1st symptom (table I). Help seeking time was more than 12 months among 36.5% of the respondents. Mean help seeking time was 11 months. Maximum respondents 87.0% were taken chemotherapy. Majority of patients 66.5% were in advanced stage.
Maximum respondents 80 (40.0%) 1st sought help from the homaeopathy. A total of 63 (31.5%) patients were diagnosed as breast cancer in 1st visit. All most half of the patients (47.0%) were diagnosed in 2nd visit. Out of 200 patients, no one started treatment in 1st visit. Twenty three percentage patients were started treatment in 2nd visit. Around three fourth of the respondents sought help to private hospital for diagnosis as well as 41 (20.5%) respondents sought help to different public hospitals and only few patients 13 (6.5%) 1st time sought help to cancer hospital.
Socio demographic characteristics |
Freq(n) |
(%) |
Education |
|
|
Illiterate |
90 |
45.0 |
Primary (1-8) |
69 |
34.5 |
Secondary(SSC)and above |
41 |
20.5 |
Occupation |
||
Housewife |
166 |
83.0 |
Service |
34 |
17.0 |
Family income (in taka) |
||
1000-5000 |
78 |
39.0 |
6000-10000 |
85 |
42.5 |
More than 10000 |
37 |
18.5 |
Mean±SD |
8937±880 |
|
Age in years |
||
26-30 |
27 |
13.5 |
31-35 |
29 |
14.5 |
36-40 |
43 |
21.5 |
41-45 |
34 |
17.0 |
46-50 |
35 |
17.5 |
More than 50 |
32 |
16.0 |
Mean ± SD |
42±9 |
|
Present illness history Help seeking time (in months) |
||
1-6 |
69 |
34.5 |
7-12 |
58 |
29.0 |
More than 12 months |
73 |
36.5 |
|
Mean 11,SD±8.6 |
|
Type of present treatment |
||
Chemotherapy |
170 |
85.0 |
Surgery and Radiotherapy |
30 |
15.0 |
Stage of breast cancer |
||
Stage I |
0 |
0.0 |
Stage II |
34 |
17.0 |
Stage III |
133 |
66.5 |
Stage IV |
33 |
16.5 |
1st Symptom present by breast cancer patients |
||
Breast lump |
149 |
74.5 |
Lump on the axilla |
26 |
13.0 |
Disfiguration of breast or nipple |
25 |
12.5 |
Total |
200 |
100.0 |
Maximum respondents not agreed with that statement ‘It was contagious′; ‘It was related with menstruation′; ‘It was related to breast feeding′; ‘There was no treatment for breast cancer′. 181 (90.5%) women were agreed with the statement, ‘I was healthy′. 162 (81.0%) agreed with the statement, ‘wait and see what would be happen′.
Help seeking pattern of breast cancer patients |
Freq(n) |
(%) |
First contact with health care service provider |
80 |
40.0 |
Post graduate physician |
64 |
32.0 |
MBBS physician |
43 |
21.5 |
Local health care service provider |
13 |
6.5 |
Number of consultation(s) for diagnosis of disease |
||
First visit |
63 |
31.5 |
Second visit |
94 |
47.0 |
Third visit |
33 |
16.5 |
Fourth and fifth visit |
10 |
5.0 |
Number of consultations for start treatment |
||
Second visit |
46 |
23.0 |
Third visit |
90 |
45.0 |
Fourth visit |
44 |
22.0 |
Fifth and sixth visit |
20 |
10.0 |
First diagnostic institution |
||
Private Hospital |
146 |
73.0 |
Public Hospital (Medical College |
41 |
20.5 |
Cancer Hospital |
13 |
6.5 |
Total |
200 |
100.0 |
Perceptions on breast cancer are summarized in table III.
Perceptions on breast cancer |
Agreed |
Not agreed |
It was contagious |
7 (3.5%) |
193 (96.5%) |
It was related with meanustration |
35 (17.5%) |
165 (82.5%) |
It was related with breastfeeding |
11 (5.5%) |
189 (94.5%) |
I was healthy |
181 (90.5%) |
19 (9.5%) |
There was no treatment for breast cancer |
22 (11.0%) |
178 (89.0%) |
It was expensive treatment |
26 (13.0%) |
174 (87.0%) |
Wait and see what would be happen |
162 (81.0%) |
38 (19.0%) |
It was a results of previous sin |
27 (13.5%) |
173 (86.5%) |
God would cure |
91 (45.5%) |
109 (54.5%) |
Fear of operation |
80 (40.0%) |
120 (60.0%) |
It would be hampered the marital relation |
7 (2.5%) |
192 (96.0%) |
Death would be obvious, no need of treatment |
12 (6.0%) |
188 (94.0%) |
Perceptions on breast cancer treatment outcome |
Frequency |
Percentage % |
Cure |
159 |
79.5 |
29 |
14.5 |
|
12 |
6.0 |
|
Total |
200 |
100 |
Perception on breast cancer treatment outcome was summarized as, 159 (79.5%) patients perceived that cancer would be cure by treatment, 29 (14.5%) respondents perceived to partially cure and 12 (6.0 %) perceived never cure.
Association of delay with present treatment of the respondents was analyzed using Pearson′s Chi-square (X2) method and results showed that there was a relationship between delay and caner stage (p<0 .0001), 1st contact of health care service provider (p<0 .0001) and no. of consultation for diagnosis and treatment (p<0 .0001).
Variables |
Total delay |
Comment |
|
Within 6 months n (%) |
More than 6months n (%) |
||
Cancer stage |
|
|
27.614 |
Early stage |
25 (73.5%) |
9 (26.5%) |
|
Late stage |
44 (26.5%) |
122 (73.5% ) |
|
1st Health care service provider |
|
|
17.645 |
Physicians |
51 (73.9%) |
56 (42.7%) |
|
Other than physicians |
18 (26.1%) |
75 (57.3%) |
|
1st diagnostic centre |
|
|
3.558 |
Private |
56 (81.2%) |
90 (68.7%) |
|
Public |
13 (18.8%) |
41 (31.3%) |
|
Number of consultation for diagnosis |
36 (26.3%) |
101 (73.7%) |
12.821 |
33 (52.4%) |
30 (47.6%) |
||
Number of consultation for treatment |
43 (27.9%) |
111 (72.1%) |
13.013 |
|
20 (43.5%) |
||
Association between perceptions and delay help seeking of the respondents was analyzed using Pearson′s Chi-square (X2) method and summarized in table V.
Variable: Perceptions |
n (%) |
n (%) |
Comments X2, df=1 |
Expensive treatment and help seeking time |
4 (15.4%) |
22 (84.6%) |
4.832, |
65 (37.4%) |
109 (62.6%) |
||
“I am healthy” and help seeking time |
57 (31.5%) |
124 (68.5%) |
7.630, |
12 (63.2%) |
7 (36.8%) |
||
“lump related with menustration and help seeking time |
6 (17.1%) |
29 (82.9%) |
5.656, |
63 (38.2%) |
102 (61.8%) |
||
“wait and see what would be happened” and help seeking time |
42 (25.9%) |
120 (74.1%) |
27.738, |
27 (71.1%) |
11 (28.9%) |
||
“feared to do operation, it might cause death” and help seeking time |
18 (22.5%) |
62 (77.5%) |
8.497, |
51 (42.5%) |
69 (57.5%) |
||
Family income and perception |
96.9%(158) |
3.1%(5) |
6.893 |
86.5%(32) |
13.5%(5) |
Results showed that there was a relationship between delay help seeking and statement of perception. Perception on expensive treatment was associated with delay help seeking (p=0.028), perception on "I am healthy″ was associated with delay (p=0.006), perception on "lump related with meanustration″ was associated with delay (p=0.017), perception on "wait and see what would be happened″ was associated with delay (p<0.0001), perception on "feared to do operation, it may cause death″ was associated with delay (p= 0.004) and perception was also related with family income (p=0.021).
Discussion
By occupation, maximum 166 (83.0%) patients were house wife, 90 (45.0%) were illiterate, a study which was conducted by Rahman M. 2015 with objective to assess the socio demographic charecteristics, tumor pattern and risk factors that affect the Bangladeshi women at Dhaka, was found that 92% were house wife, 51.4% were illiterate18 and also found 60% cases were illiterate which was conducted by Jabeen S. at 2013 with the objective to determine risk factors associated with breast cancer.19 Maximum respondents 43 (21.5 %) were in middle age group at 36-40 years age group and mean age was 42 years ±SD was 7 (range 26-69 years). From another study it was found that the mean age 44.7 years18 and also found the mean age 43.55(±SD 9.63) years.19 According to age structure, maximum female populations are in middle age group. It is around 20% (33,266,733 vs. 166,280,712) of total population.20 This is the reason for prevalence of breast cancer more in the middle age group.
Out of 200 respondents, 190 patients of breast cancer assumed that delay is help seeking was due to negative perceptions. Results indicated that the majority of women disagreed with the statement (such as contagious, menstruation, breastfeeding, expensive treatment, previous sin, hamper marital relation and death was obvious) and were not to blame for the occurrence of their breast symptoms. A study showed that maximum women disagreed that due to internal factor (such as germ, virus, diet, genetics, own behavior, state of mind) might be cause cancer.16
After feeling symptom, what their perceptions on breast cancer were asked, out of 10, almost 9 respondents were perceived that they were healthy. There was a significant difference between delay and that statement (X2= 7.630, p= 0.006). Fear to do operation 80 (40.0%) had significant relationship with delay in help seeking (X2=8.497, p=0.004). There was also an association with family income and perception (X2=6.893, p=0.021). Out of 10, almost 8 respondents perceived to wait and see what would be happened. That statement had significant relationship with delay help seeking (X2=27.738, p=< 0.0001). Some 80% of the respondents perceived that they would be cure after treatment. In a study, it was found that 262 (59.3%) respondents thought that breast symptom would improve in time. Majority of the women 235 (53.8%) in that sample agreed that the symptom occurred by a chance. A study showed that those who perceived “my breast symptom is likely to be permanent rather than temporary (X2=11.43, p=0.022, df=4) had significant difference with delay in help seeking. My breast symptom will last for a long time had also a significant difference with delay in help seeking (X2=13.71, p=0.008, df = 4).20 Though the socio-demographic characteristics of the respondents were almost same, significant difference was not found with delay help seeking but in a study by Friedman LC, 2006 by multivariate analysis with objective to find out the delay in seeking medical help, it was found that younger age (p ≤0.05), less education (p≤0.01), absence of a lump (p ≤0.05), lower perceived risk (p ≤0.001), less spirituality (p ≤0.01) and not wanting to think about breast symptom(s) (p ≤0.05) were related to delay.21 Due to geographical variation perceptions varies region to region be done, pinpoint comparison could not.
Conclusion
Management success in breast cancer need to provide appropriate knowledge on perception. Perception of the respondents is the first step to guide and take correct decision from where they first seek medical help. It should ensure easy availability of diagnostic facilities at primary level of health care system and to raise the awareness in breast cancer at community level.
Acknowledgement
Author acknowledge the valuable suggestions of Professor (Dr.) Md. Ziaul Islam, Department of Community Medicine, NIPSOM and Professor (Dr.) Md. Mizanur Rahman, Department of Surgical Oncology, NICRH, Mohakhali, Dhaka to conduct this study.
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