Breast cancer screening awareness, practice, and perceived barriers: A community‐based cross‐sectional study among women in south‐eastern Bangladesh

Abstract Background and Aims Breast cancer is a leading cause of mortality in Bangladesh. An early‐stage screening is the best way to reduce both the morbidity and mortality burden of breast cancer. The study evaluated awareness, practice, and perceived barriers toward breast cancer screening in Bangladesh. Methods A community‐based cross‐sectional study was conducted from October 2021 to December 2022 in Chattogram, Bangladesh, where 869 women (18 years or above) were randomly selected in this study. Results Among 869 participants, 47.3% of women were recruited from urban areas and 52.7% participated from rural areas. Only 32.68% of respondents (urban vs. rural: 44.28% vs. 22.27%) were aware of breast self‐examination (BSE) and 52.47% of respondents (urban vs. rural: 63.75% vs. 42.36%) had ever heard Clinical Breast Examination (CBE), respectively. Among the respondents, 27.73% (urban vs. rural: 40.15% vs. 16.59%) performed their BSE, and only 14.61% of respondents (urban vs. rural: 21.90% vs. 8.08%) had ever visited for CBE. Women residing in rural areas were approximately three times (AOR: 0.36 [95% CI: 0.25–0.52], AOR: 0.37 [95% CI: 0.23–0.58]) less likely to perform BSE and CBE, respectively, than urban dwellers. We found that higher‐educated women tend to do more BSE and CBE than women with low levels of education. Perceptions of having “no symptoms” and being “risk‐free” are leading barriers to breast screening among women. Conclusion Poor awareness and practice were observed in screening among the urban and rural women in Bangladesh. Urban area dwellers had comparatively better understanding and practice than rural dwellers. We think extending health education and health promotion activities toward breast cancer screening is essential in this region.


| Study design and area
This was a cross-sectional study of women in the Chattogram district of Bangladesh for the period of 15 months (October 2021 to December 2022).Two thanas (small administrative area in urban area) (Bandar, Halishahar) from urban area and two upazilla (small administrative area in rural area) (Sitakunda, Hathazari) were selected randomly from 16 thanas and 15 upazillas of Chattogram, respectively.

| Sampling technique
Multistage random sampling was used to select participants.On the first stage, two thanas from urban area and two upazilas from rural area of Chattogram were randomly selected by using lottery.Then households of thanas and upazilas were selected by utilizing the head and tail of coin procedure.In the last stage, one woman was selected randomly for interview if the household had one or two women and two women were interviewed if the household had more than two women.

| Sample size calculation
Study sample was calculated by using the following formula n = Z 2 pq/ d 2 , where n is the required sample size, p the expected (0.5) proportion of study population with awareness and practice of breast cancer screening, q = 1 − p, and is the level of precision at 5%. n = 1.96 2 × 0.5 × 0.5/(0.05) 2 = 384.By considering a design effect of 1.5 due to multistage sampling and a 20% nonresponse rate, we estimated a total sample size of 691.Rounding up a total of 1000 participants (500 women from urban areas and the same number from rural areas) were approached for the study participation and 869 (86.9%) agreed to participate.

| Data collection tools
A structured questionnaire was designed by using previously published studies 11,12,[16][17][18] that adapted validated questions.It consists of four sections, including sociodemographic characteristics, breast cancer examination awareness, practice, and perceived barrier of breast cancer examination.The questionnaire was prepared in English and then translated into local language for better understanding.A face-to-face interview was done for each participant by trained female data collectors.

| The content of the questionnaire was as follows
• Sociodemographic data: age (we were looking for participants aged 18 years or more.According to World Health Organization (WHO) women aged 20-39 years should screen their breasts once every two-3 years by trained healthcare provider and from 40 years once in a year. 19Based on that, we categorized the family income into less than 20,000 BDT, 20,000-40,000 BDT, 40,001-60,000 BDT and more than 60,000BDT), family type (nuclear and joint/extended), and religion (hindu and muslim).
• General awareness of breast cancer and its screening (awareness was defined as heard about breast cancer, breast cancer screening, BSE and CBE awareness for breast screening).
• BSE and CBE practice for breast cancer screening.

| Data analysis
Data analysis was carried out by using STATA statistical package version SE 17.0.Descriptive statistics were used to describe the sociodemographic characteristics of urban and rural area.Univariable and multivariable logistic regression were applied to identify significant predictors of BSE and CBE practice.To analyze the degree to which dependent and independent variables are associated, an odds ratio (OR) and 95% confidence interval (CI) were used.Moreover, perceived barrier toward screening among the women was displayed descriptively.

| Ethics issues
The study was approved by the Institutional Review Board (IRB) of the University of Creative Technology Chittagong, Bangladesh Ref: IRB/ UCTC/2021/04.Confidentiality of participants data was maintained, and the participants were included in the study with verbal consent.

| Sociodemographic characteristics of participants
Of the 869 respondents, 411 (47.3%) were from urban areas and 458 (52.7%) resided in rural areas.There was no significant difference in the age groups of the participants between the two regions, and most of the participants in urban and rural areas (69.34% and 73.80%) belonged to 18-39 years age group.Besides that, no significant difference was observed in religion types and muslim was the prevalent group in both regions (94.4% and 93.01%).However, types of family, family income, marital status, educational status, and occupational status of the Awareness of breast selfexamination (BSE) among urban and rural women.
participants were significantly different from the urban to rural regions.
Majority of the participants were housewives (80.29% and 87.12%), married (85.40% and 89.96%), from nuclear families (88.32% and 60.48%), completed secondary education (33.82% and 47.82%), having 20,000 to 40,000 BDT family income (55.96% and 57.86%).However, the proportion of higher education and higher income groups is comparatively high in urban areas than in rural areas.The sociodemographic characteristics of urban and rural area participants are tabulated in Table 1.

| Awareness and practice of breast cancer screening
The proportion was comparatively higher for urban women than rural women in both awareness and practice.About 77% of the

| Barriers toward breast cancer screening
The bar diagram in Figure 4 shows the major perceived barriers toward breast cancer screening.Regarding the perceived barrier   This study is one of the few community-based studies investigating awareness, practice, and perceived barriers to breast cancer screening among urban and rural women in Bangladesh.The study findings showed that despite having a high awareness of breast cancer, most women were unaware of breast cancer screening in terms of both BSE and CBE.The results agreed with the study conducted in Bangladesh and Ethiopia, 11,21 implying that awareness of screening for breast cancer needs to be addressed in Bangladesh.
The practice of BSE and CBE was even worse among the women in this region.A similar finding was found among university students in Bangladesh and in a Nigerian study.However, a Malaysian study observed a different scenario where more than 50% of women practised both BSE and CBE. 23This gap in screening uptake in different regions probably awareness varieties on breast cancer screening among the respondents.A previous study showed educated and employed women were more aware of screening, 24 as we found more women with higher education and higher income were living in the urban area with better screening awareness and practice than their counterparts.
Raising awareness of the importance of screening, as shown by a recent study in Bangladesh, could be a key factor in increasing screening practice among women in this region. 9This study also reported the uptake of for breast cancer is poor in a rural area, which aligns with our findings that urban dwellers BSE and CBE practices proportion was almost three times better than rural dwellers.However, the breast cancer screening proportions were similar among urban and rural dwellers in developed countries like the United States. 25Current prediction analysis revealed the regional disparity.Rural dwellers were three times less likely to perform BSE and CBE than urban dwellers.7][28] On the contrary, a Vietnamese study reported no association was found between CBE uptake and area of residence. 29The possible explanation could be easy accessibility to information on screening and the tendency to seek more health care by the urban women than the rural women.
Our current study also explored other sociodemographic variables like education and family income.The women with secondary education and above were more likely to perform BSE and CBE than those with primary education.Evidence from other studies 11,23,30 supported the significant association between educational attainment and better screening practice.In the case of the monthly income, women who have 20,001 to 40,000 BDT family income were two times (AOR: 1.96 [95% CI: 1.2-3.0])more likely to perform BSE than the lower income group, but no association was found in CBE uptake which is consistent with other studies. 27,29In contrast, married women were more prone to do breast cancer screening than the single women we found.A study reported marital status influenced the better utilization of breast, cervical, and colorectal screening. 31This is probably due to better breast cancer awareness among married women. 32other aim of the study was to determine the perceived barrier toward screening along with the awareness and screening practice.
The result of the study shows that most respondents did not feel obstructed in screening due to fear of clinical examination, social stigma, shyness of uncovering their breasts, and no time to do breast screening.However, a previous study in Bangladesh reported embarrassing to tell people and uncovering breasts were the leading barriers to screening. 12Some previous studies revealed that embarrassment, fear of screening, and lack of awareness were major impediments to breast cancer screening. 33,34This dissimilarity of the findings could be due to differences in the study place.Our study confirmed that a lack of awareness programs was a major barrier to getting information about screening.Moreover, the perception of having no symptoms and being free from breast cancer risk discouraged them from going for screening, which is consistent with the findings from a previous large population-based study in Bangladesh. 11This study findings could effectively design interventions on health education and promotion programs for breast cancer screening in developing countries like Bangladesh.
One of the strengths of the study is using multistage sampling to select samples randomly from the population.A decent sample size was taken from urban and rural communities that may reflect the characteristics of the general population.Due to the cross-sectional study design, clear evidence about causal association of risk factors with breast cancer screening cannot be ensured.Moreover, the selfreported data were collected by an interviewer-administered questionnaire.So, recall bias from respondents' side and interviewer bias are possible.

F I G U R E 2
Frequency of breast self-examination (BSE) practice among urban and rural women.F I G U R E 3 Frequency of clinical breast examination (CBE) practice among urban and rural women.

F I G U R E 4
Perceived barrier toward breast cancer screening among the participants.
T A B L E 2 Breast cancer screening awareness and practice.
Factors associated with breast self-examination.
T A B L E 3 toward breast cancer screening, majority of the respondents did not feel any obstacles by "social stigma" (74.10%; urban vs. rural: 77.13% vs. 71.4%),"fear of clinical examination" (66.28%; urban vs. rural: 72.68% vs. 60.70%) and "shy to uncover their breasts" (66.97%; urban vs. rural: 71.95% vs 62.66%) for breast cancer screening.However, majority of the respondents felt "having no sign and symptoms" of breast cancer (92.86%; urban vs. rural: 91.73% vs. 93.89%)and "free constrained them from screening.About 84.34% of respondents (urban vs. rural: 75.18% vs. 92.58%)reported "lack of awareness program" and 88.14% respondents (urban vs. rural: 83.21% vs. 92.58%)addressed "lack of governmental and nongovernmental organizations working on breast cancer screening" as the barriers to getting information on breast cancer screening.
14,22T A B L E 4 Factors associated with clinical breast examination.