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Factors influencing breast cancer screening practices among women worldwide: a systematic review of observational and qualitative studies

BMC Women's Health volume 24, Article number: 268 (2024) Cite this article

Abstract

Background

The variation in breast cancer incidence rates across different regions may reflect disparities in breast cancer screening (BCS) practices. Understanding the factors associated with these screening behaviors is crucial for identifying modifiable elements amenable to intervention. This systematic review aims to identify common factors influencing BCS behaviors among women globally.

Methods

Relevant papers were sourced from PubMed, Scopus, Embase, and Google Scholar. The included studies were published in English in peer-reviewed journals from January 2000 to March 2023 and investigated factors associated with BCS behaviors.

Results

From an initial pool of 625 articles, 34 studies (comprising 29 observational and 5 qualitative studies) with 36,043 participants were included. Factors influencing BCS behaviors were categorized into nine groups: socio-demographic factors, health status history, knowledge, perceptions, cultural factors, cues to action, motivation, self-efficacy, and social support. The quality appraisal scores of the studies ranged from average to high.

Conclusions

This systematic review highlights factors pivotal for policy-making at various levels of breast cancer prevention and assists health promotion professionals in designing more effective interventions to enhance BCS practices among women.

Peer Review reports

Background

Breast cancer stands as the most commonly diagnosed cancer among women worldwide, affecting both developed and developing countries [1]. Statistical analyses indicate that while wealthier nations report higher breast cancer incidence rates, less developed countries suffer from higher relative mortality rates [2].

In high-income countries, including the United Kingdom, Australia, and Eastern Europe, over 60% of women are diagnosed at stages one and two of the disease, significantly improving their survival rates. Conversely, women in low-income countries often seek treatment at advanced disease stages when it has metastasized to other organs [3].

Differences in cancer incidence rates across populations may be attributable to the variance in risk factor prevalence and the implementation or uptake of screening programs [4].

Routine screening is pivotal in detecting breast cancer at an early, more treatable stage, significantly reducing mortality rates [5]. The primary methods of screening include breast self-examination (BSE), clinical breast examination (CBE) by a healthcare professional, and mammography (MMG), all of which have been demonstrated to lower mortality rates from breast cancer in various studies [6,7,8,9].

Despite numerous interventions and educational efforts aimed at promoting participation in BCS programs, recent studies indicate a continuing rise in mortality rates and a persistently low participation rate among women, particularly in less developed countries [1, 10]. For instance, recent figures show that only 13.6% of Malaysian, 0.3% of Egyptian, and 3.8% of Ethiopian women have undergone MMG in the past two years, compared to 81%, 88%, and 70% in Belgium, Australia, and the United States, respectively [11,12,13,14,15,16]. These disparities highlight the crucial need for developing and implementing effective strategies based on scientific and reliable research to enhance screening behaviors across different societies.

Given the significance of BCS and the dire predictions that both morbidity and mortality from breast cancer will more than double by 2035 [3], it becomes imperative to conduct a comprehensive review of the published literature. This systematic review aims to [1] summarize current knowledge on factors influencing BCS behaviors and [2] identify factors relevant to enhancing screening behaviors among women worldwide. Achieving these objectives and leveraging the findings of this research could empower policymakers, researchers, and health promotion professionals to devise more effective prevention policies and interventions, thereby improving BCS behaviors through well-informed strategies.

Methods

This systematic review was registered with PROSPERO under the registration number CRD42023432810. The presentation of findings adheres to the PRISMA checklist standards (Additional file 1).

Search Strategy

The research question, structured according to the PICOS framework, was: “What are the factors impacting BCS behaviors among women worldwide?”

The PICOS elements defined were as follows:

  • Population: Healthy individuals aged 15 years or older, encompassing all genders, races, and geographic locations.

  • Intervention (Influential Factors): This includes socio-demographic factors, health history, knowledge, perceptions, cultural factors, cues to action, motivation, self-care, and social support.

  • Comparison Group: Subpopulations and subgroups differentiated by socio-demographic variables.

  • Outcome: Practices related to BCS.

  • Study Design: The review included cross-sectional, retrospective, prospective, and qualitative studies.

Four key search concepts and their synonyms (Table 1) were identified for the search. The international databases searched included PubMed, Scopus, Science Direct, Embase, and Google Scholar. Berenguer and Sakellariou’s search strategy [17] was adopted. The search concepts, along with their synonyms (utilizing truncations and wildcards, as indicated in Tables 1 and Additional file 2), where the asterisk ‘*’ was applied where appropriate, and subject heading terms were combined using the Boolean operators ‘OR’ within concepts, and ‘AND’ to combine concepts, thus developing the final search strategy (Additional file 2).

Table 1 Search key terms achieved from the research question
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Inclusion and exclusion criteria

Studies were included if they:

  1. 1.

    Reported on MMG, CBE, or BSE as methods for BCS, in alignment with recommendations by international health organizations.

  2. 2.

    Were published in peer-reviewed journals between January 2000 and March 2023.

  3. 3.

    Addressed factors associated with BCS behaviors, focusing on associated factors rather than the effects of interventions.

  4. 4.

    Employed quantitative or qualitative research designs.

  5. 5.

    Included participants aged 15 years or older.

The exclusion criteria for the studies were:

  1. 1.

    Duplicate publications across databases.

  2. 2.

    Non-original research articles, including dissertations, reviews, case reports, editorials, oral and poster presentations, and book chapters.

  3. 3.

    Publications in languages other than English.

  4. 4.

    Preprints are not subjected to peer review.

  5. 5.

    Studies focusing on general cancer screening are not specific to breast cancer.

  6. 6.

    The research concentrated on other preventative behaviors or early detection methods unrelated to BCS.

  7. 7.

    Studies focused on factors associated with the second BCS participation round.

  8. 8.

    Research involving women with specific conditions, such as those who are sick or vulnerable.

Study selection

The selection followed PRISMA guidelines. Initially, duplicates across databases were removed. Titles and abstracts were then reviewed for relevance, and articles not meeting the inclusion criteria were discarded. Subsequently, full texts of the remaining studies were evaluated for relevance, with any further non-compliant studies excluded. This review process was independently conducted by two researchers, with any discrepancies resolved through discussion.

Quality assessment

Following numerous academics’ recommendations, the methodological quality of the included studies was assessed, and a Methodological Quality Score (MQS) was assigned. Experts evaluated each study’s conceptual and methodological rigor, resolving discrepancies by consensus. Based on Bernstein’s standards [18] and as explained by Patton [19], the assessment criteria included theoretical framework usage, study design, sample size, measurement instruments, data analysis, and reporting on reliability and validity. Quantitative studies were scored on a scale from 0 to 19, and qualitative studies from 0 to 14, with higher scores indicating higher methodological quality. Studies scoring below 60% were excluded.

Data extraction and synthesis

Data were independently extracted by two researchers (BT and HSH), using a pre-designed tool to collect methodological details, including first author, publication year, study design, data source, study location, sampling strategy, sample size, data collection techniques, participant age, BCS method, and conceptual framework. For quantitative studies, additional data on screening participation rates and identified factors associated with BCS behaviors were noted. Qualitative studies included thematic information extracted for analysis.

Results

An initial search yielded 625 articles from the specified databases. After removing duplicates and screening titles and abstracts, 118 papers were selected for full-text evaluation. Ultimately, 34 papers comprising 29 observational studies and 5 qualitative studies, with 36,043 participants, were included in the final review. The study selection process is illustrated in Fig. 1.

Fig. 1
figure 1

PRISMA flow diagram of the study selection procedure

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Quality of included studies

None of the studies achieved the highest possible score. A majority of the studies were cross-sectional designs (82.4%), and over half (64.7%) included large samples (more than 300 participants). Furthermore, 67.7% of the studies grounded their findings in specific theoretical frameworks. Approximately half reported the psychometric properties of their assessment instruments. A significant portion (85.3%, N = 29) of the studies were quantitative and utilized both descriptive and advanced statistical analyses, such as t-tests, multiple regression, logistic regression, and multivariate analysis. The qualitative studies (14.7%, N = 5) primarily employed content and thematic analysis. All quantitative studies assessed the statistical significance of factors associated with BCS behaviors (Table 2).

Table 2 Criteria for methodological quality assessment of reviewed studies and the frequency distributions of each criterion
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Characteristics of included studies

The 34 articles that met the inclusion and exclusion criteria were geographically diverse: 20 studies were conducted in Asia [10, 11, 20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37], 5 in America [16, 38,39,40,41], 4 in Europe [14, 42,43,44], 4 in Africa [12, 13, 45, 46], and 1 in Australia [15].

The sample sizes ranged from 8 to 11,409 participants, with the age of participants spanning from 15 to 82 years. Except for one qualitative study focusing on Arab men’s perceptions of female BCS [34], all participants were women.

There was variability in the BCS methods and the measurement of related factors across studies. Eleven studies identified CBE, BSE, or MMG as the screening methods [13, 20, 22, 29, 30, 32, 34, 36, 37, 41, 46]; four defined BSE or MMG [12, 25, 31, 35]; one mentioned CBE or MMG [11]; one mentioned CBE or BSE [24]; one specified CBE alone [39]; six identified BSE alone [23, 26, 28, 33, 45, 47]; and ten focused solely on MMG [14,15,16, 27, 38, 40, 42,43,44, 48].

The reported BCS rates varied significantly across studies, from 0.3 to 62% for BSE, 2.5–41% for CBE, and 0.3–88.1% for MMG (Table 3).

Table 3 Summary of the characteristics of included studies reviewed
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Factors associated with BCS behaviors

The question of “What factors impact BCS behaviors in women worldwide?” is comprehensively answered through the analysis presented in Tables 4, 5 and 6. These tables delineate the factors influencing BSE, CBE, and MMG, respectively, as identified in the 34 reviewed articles.

The factors identified are categorized into nine key areas:

  1. 1.

    Socio-demographic Factors: This includes age, education level, income, marital status, and employment status, highlighting how these variables influence screening behaviors.

  2. 2.

    Health History: Past health experiences, family history of breast cancer, and personal health beliefs play a significant role in an individual’s decision to undergo screening.

  3. 3.

    Knowledge: The awareness and understanding of breast cancer and the benefits of early detection through screening methods.

  4. 4.

    Perceptions: Women’s beliefs and attitudes towards breast cancer risk, the effectiveness of screening, and the healthcare system’s role in cancer detection.

  5. 5.

    Cultural Factors: How cultural beliefs, norms, and societal expectations shape attitudes towards breast health and screening practices.

  6. 6.

    Cues to Action: External prompts, such as recommendations from healthcare professionals, health campaigns, or peers’ experiences, encourage women to seek screening.

  7. 7.

    Motivation: The intrinsic and extrinsic motivators drive women to participate in screening activities.

  8. 8.

    Self-care: The degree to which women prioritize their health and well-being, including the proactive pursuit of health screenings.

  9. 9.

    Social Support: The influence of family, friends, and community networks in supporting or hindering screening behaviors.

Table 4 Identified factors associated with breast self-examination behaviors among women around the world in the 34 reviewed articles
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Table 5 Identified factors associated with clinical breast examination behaviors among women around the world in the 34 reviewed articles
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Table 6 Identified factors associated with mammography behaviors among women around the world in the 34 reviewed articles
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Discussion

The primary goal of this study was to identify the universal factors influencing BCS behaviors among women globally. Although most countries offer BCS programs [17], the nature and implementation of these programs vary significantly across different health systems and populations [49]. Consequently, the BCS methods examined in this review varied, reflecting these disparities. MMG, recognized for its efficacy in clinical studies, is predominantly used in developed countries due to its higher costs [8]. Conversely, in developing countries, BSE stands out as a widely adopted, cost-effective method for early detection [50].

Moreover, the rates of screening methods reported in the literature show considerable international variation. Countries like Sweden, Belgium, the USA, and Australia report high MMG screening rates [14,15,16, 43], whereas BSE is more prevalent in countries like Egypt, Ethiopia, Turkey, Iran, and Iraq [12, 13, 25, 26, 32], often falling below the WHO’s recommended screening rates [49].

The WHO underscores the importance of high participation rates in screening programs to enhance their effectiveness [49]. Understanding the factors influencing participation enables health systems to adopt comprehensive strategies for prevention, early diagnosis, and BCS promotion.

Over half of the studies reviewed focused on socio-demographic factors as determinants of screening behaviors, identified in previous research as facilitators and barriers [51, 52]. Findings indicate that demographic variables such as age, education level, income, and employment status significantly influence screening rates.

While socio-demographic status is recognized as a crucial determinant of access to BCS in both high-income [51, 52] and middle-income countries [10, 17], studies in European countries with organized screening programs report no correlation between screening participation and socio-demographic variables [53]. A 2011 study exploring the impact of socioeconomic inequalities on screening participation highlighted that such disparities exist even without financial barriers [54]. These variations necessitate careful interpretation, considering women’s diverse challenges in accessing screening services worldwide, including geographical, economic, and cultural obstacles.

For instance, despite Qatar’s provision of comprehensive medical services at no cost, including BCS, cultural barriers have led to only a third of eligible women utilizing these services [34]. Thus, offering organized screening programs with equitable access could gradually mitigate socioeconomic disparities.

The review also highlights that beyond a family history of breast cancer and personal breast health issues, fertility-related challenges, such as infertility and hormonal imbalances, influence screening behaviors. This finding aligns with systematic reviews from China and the USA, which examined screening factors among different populations [55, 56]. Women with personal or familial health histories may perceive a higher susceptibility to breast cancer, thereby increasing their utilization of healthcare services for screening and diagnostic tests. This heightened awareness and concern about breast cancer risk can motivate women to adopt preventive measures, including screening. However, it is notable that many women may not pursue screening until symptomatic or following the discovery of breast cancer in close relatives [57, 58].

The findings of the study reveal that women with comprehensive knowledge about breast cancer risk factors, symptoms, and screening methods are more likely to participate in screening programs. Conversely, women who have not undergone screening often lack awareness or believe that once screened, repeat screenings are unnecessary [59]. This lack of knowledge has been identified as a critical barrier to screening participation among Iranian and Asian women and as a predictive factor for the late diagnosis of breast cancer in Canada [10, 60, 61]. However, Schlueter’s study found no correlation between the level of knowledge and screening behaviors [62], indicating the complexity of this relationship.

Educational interventions targeting breast cancer awareness and screening guidelines are crucial for improving women’s knowledge and participation rates.

Perceptual factors significantly influence screening behaviors, including fewer perceived barriers and higher self-efficacy. A Chinese study highlighted reduced perceived barriers as a predictive factor for screening participation [55]. Main barriers identified include fear [34, 42, 46, 48], anxiety [29, 30], worry [22, 63], religious beliefs and fatalism [32, 46, 48], financial constraints [34], language barriers [29, 39, 40], and embarrassment [63]. Although fear can motivate screening behavior in some contexts [56], it is predominantly an emotional barrier in the findings.

Types of fear recognized include the fear of mastectomy, diagnosis of cancer, and stigmatization [34, 46, 48]. Consedine et al. noted that while fear of cancer could facilitate screening, specific fears—such as those associated with medical procedures or diagnosis—often deter women from participating [64]. A meta-analysis further linked fear of breast cancer to screening behaviors [65], suggesting that mitigating fear through education and positive screening experiences could enhance participation rates.

Cultural factors, particularly religious beliefs, and fatalism, notably impact screening behaviors. Some Muslim women believe BCS is unnecessary, viewing cancer as a divine challenge or part of destiny [63]. This fatalistic view, a belief in the health locus of control being external (chance or divine will), can lead to passive health behaviors [66]. While some studies show no significant impact of religious beliefs on screening behaviors [67], the intertwined nature of these beliefs with culture and religion necessitates nuanced interventions.

Effective strategies might involve integrating breast cancer awareness and early diagnosis information within the framework of existing belief systems leveraging religious leaders to promote health messages aligned with spiritual teachings. Such approaches, using religious and spiritual elements in health messaging, have been shown to encourage screening behaviors among women [11].

The results of this review highlight that women are more likely to engage in BCS behaviors when they receive information from healthcare teams, social media, or other sources compared to those who do not consult with healthcare professionals or use social media for health information. Jones et al. emphasized that recommendations and reminders from healthcare providers are among the most effective means of directing women toward MMG and other screening tests [68]. A 2019 study further showed that ignoring cues to action, such as letters, messages, and reminder calls, correlates with lower MMG participation rates [69].

In the modern era, widespread access to information through digital media, advancements in technology, and the introduction of electronic health tools have facilitated the use of these platforms in cancer screening campaigns. For instance, smartphone applications that remind users about screening schedules and provide preventive advice through text, images, and videos represent an innovative approach to enhancing screening participation.

This review also underscores a significant link between motivation and BCS behaviors. Khazaee-Pool et al. found that motivational solid factors, such as valuing life and health responsibility, significantly encourage screening participation [21]. Moreover, studies among diverse racial and ethnic groups have identified a clear association between motivation and increased screening activities [70].

Various socio-psychological barriers, including attitudes, cultural beliefs, and communication issues, have been identified as impediments to motivation [71]. Factors contributing to low motivation for MMG include the perceived unimportance of testing, lack of support, time constraints, cost concerns, familial obligations, and a busy lifestyle [48]. Therefore, interventions aimed at enhancing motivational self-efficacy could significantly improve screening participation.

As part of self-care practices, regular health check-ups have been shown to predict screening behaviors. Reviews have highlighted a correlation between infrequent mammograms and breast exams among Asian and Korean-American women with irregular gynecological visits [51, 59]. Although MMG can be performed without direct referrals in some countries [59], the lack of commitment to regular check-ups remains a barrier. As Pasket et al. reported, while 75% of women acknowledged the importance of periodic exams, 67% indicated that their physicians did not actively encourage MMG [72].

Improving knowledge about self-care and self-regulation is crucial for fostering regular health examination habits. The health system’s role in scheduling periodic health assessments and encouraging adherence is also vital, as demonstrated by research from the Netherlands, which linked pre-scheduled appointments and proactive general practitioner involvement to higher screening rates [49].

Regarding social support, assistance from healthcare teams and family members significantly influences screening behaviors. Lack of partner support and fear of familial disruption post-diagnosis have been noted as significant barriers among African-American women [68]. Support from family and friends, providing both financial and emotional backing, can bolster confidence, reduce fear, and encourage screening participation [21, 59, 73].

The review also points out that women’s financial independence and employment status in certain regions are critical in health decision-making. Conversely, many women rely on male family members to make health decisions, a group that requires targeted support from health teams for emotional, instrumental, and informational needs. Leong et al. found that social support not only reduces depression but also promotes healthier behaviors [74]. Thus, establishing support networks and self-help groups can enhance women’s knowledge, experience, and motivation regarding BCS, ultimately fostering a community of mutual encouragement and support.

Strengths

This systematic review meticulously evaluated the quality of included studies to ensure their reliability and relevance. A unique aspect of the analysis is the consideration of men’s attitudes and perceptions toward BCS, acknowledging the influence of gender dynamics on screening behaviors. A comprehensive approach was undertaken, analyzing factors affecting BCS behaviors across quantitative and qualitative studies and categorizing them based on their impact on three distinct screening behaviors: BSE, CBE, and MMG. This nuanced categorization provides a detailed understanding of the diverse influences on BCS practices.

Limitations

This research was confined to online studies, potentially overlooking valuable research indexed in databases such as PubMed, Scopus, Embase, and Google Scholar or available only in print. The restriction to English-language publications may have excluded pertinent non-English studies, introducing language bias. The review’s predominance of cross-sectional studies limits the ability to ascertain causal relationships between the factors studied and screening behaviors. Additionally, the reliance on self-reported data raises concerns about the accuracy of the findings, given the potential for recall bias or the desire of participants to present themselves in a socially desirable light.

The heterogeneity of the included studies—in terms of study design, geographic location, methodological approach, demographic characteristics, sample size, screening methods employed, and the intervals between screenings—complicates direct comparisons and may affect the generalizability of the findings.

Conclusion

This systematic review synthesizes a broad array of research on the factors influencing BCS behaviors among women worldwide. By examining various screening methods and participation rates, along with identifying determinants of screening behavior, this study contributes valuable insights to the field of public health. The findings highlight the complex interplay of factors affecting screening behaviors and provide evidence-based guidance for policymakers and health promotion professionals. This knowledge is crucial for developing targeted interventions that can effectively encourage BCS practices, ultimately contributing to breast cancer prevention and early detection.

Availability of data and materials

This published article and its supplementary information files include all data generated or analyzed during this study.

Abbreviations

BCS:

Breast cancer screening

BSE:

Breast self-examination

CBE:

Clinical breast examination

MMG:

Mammography

MQS:

Methodological quality score

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

WHO:

World Health Organization

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Acknowledgements

We thank the Isfahan University of Medical Sciences and the Isfahan School of Health for their support. Our thanks also go to all who contributed to the conceptualization, execution, and analysis of this work.

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This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Student Research Committee, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran

    Banafsheh Tavakoli

  2. Department of Epidemiology and Biostatistics, Isfahan University of Medical Sciences, Isfahan, Iran

    Awat Feizi

  3. Department of Health Education and Health Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran

    Fereshteh Zamani-Alavijeh & Hossein Shahnazi

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Contributions

B.T. and H.S. conceived the project; B.T. and H.S. performed the literature search; all authors contributed to the literature analysis and synthesis of data; F.Z. and A.F. created the figures and tables; B.T. and H.S. wrote the review. All authors were involved in further editing and finalizing the manuscript.

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Correspondence to Hossein Shahnazi.

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This manuscript received ethical approval from the Isfahan University of Medical Sciences (Science code: 3400585; Ethical Code: IR.MUI.RESEARCH.REC.1400.343). Given the nature of this systematic review, consent to participate was not applicable.

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Tavakoli, B., Feizi, A., Zamani-Alavijeh, F. et al. Factors influencing breast cancer screening practices among women worldwide: a systematic review of observational and qualitative studies. BMC Women's Health 24, 268 (2024). https://doi.org/10.1186/s12905-024-03096-x

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BMC Women's Health

ISSN: 1472-6874

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