In sub-Saharan Africa (SSA), breast cancer is the most commonly diagnosed cancer among women, while cervical cancer remains the leading cause of cancer death. Women often fail to recognise or misinterpret possible symptoms, so breast and cervical cancer symptom awareness information can promote timely help-seeking behaviour, diagnosis and start of treatment.
To identify tools that have been utilised to measure breast and cervical cancer symptom awareness in SSA and to establish if such tools have been validated in SSA populations.
A scoping review of articles published between January 1997 and February 2017, written in English and describing primary research in breast and/or cervical cancer symptom awareness-related topics in SSA contexts, was undertaken across five databases. The approach was supported by Colquhoun et al.’s methodological framework for scoping reviews.
A total of 41 studies were included from 11 SSA countries. Almost half (20/41) used breast and/or cervical cancer symptom awareness tools but did not report on tool validation processes. The rest (21/41) made reference to some tool validation, yet only two reported a detailed account of their tool validation processes. One explored lay perceptions of breast cancer, while the other sought to establish the validity and reliability of a UK tool in a Kenyan context.
The findings point to the dearth of comprehensively validated and culturally relevant tools to measure breast and cervical cancer symptom awareness in the SSA context. They have informed the development and validation of an African Women Awareness of CANcer (AWACAN) tool, which can support the development and evaluation of interventions relevant to the SSA context.
Breast and cervical cancers are the leading cause of cancer morbidity and mortality in women. In sub-Saharan Africa (SSA), breast cancer is the most commonly diagnosed cancer among women, while cervical cancer remains the leading cause of cancer death.
Accurate measurement of cancer symptom awareness, knowledge and beliefs using validated tools would enable precise measurement of the impact of cancer awareness interventions. Against this background, we conducted a scoping review to identify tools which have been utilised to measure breast and cervical cancer symptom awareness in SSA and evidence of their validity. Scoping reviews differ from systematic reviews in scope, criteria and quality assessment.
The review was guided by two questions: (1) Which tools have been used to measure symptom awareness in SSA? (2) Have these tools been validated in any SSA populations? Following Colquhoun et al.,
Identification of relevant studies commenced with a basic search for the terms ‘breast cancer, cervical cancer, awareness, beliefs, measures, Africa’ on Web of Science, Scopus and Ebscohost electronic databases. We then sifted through key studies for potential broader search terms, which generated a list of terms (see
We included peer-reviewed journal articles published between January 1997 and February 2017, written in English and describing primary research in breast and/or cervical cancer symptom awareness-related topics in SSA contexts. Given the focus on tool validation which involves evaluating ‘if the measurement tool employed actually measures the intended research concept or construct or if the measurement tools used to quantify the variables provides table or consistent responses’,
This article followed all ethical standards for a research without direct contact with human or animal subjects.
The PRISMA flow diagram and checklist (see
PRISMA flow diagram.
Forty-one studies were included. In these studies, cancer awareness is discussed from various perspectives including symptom knowledge, awareness, perceptions and attitudes about breast cancer, cervical cancer or cancer in general, including risk factors. The studies also discussed healthcare use including delays in seeking treatment, pathways to treatment and screening practices.
Twenty of the 41 studies used symptom awareness tools but gave no detail on tool validation processes
Symptom awareness tools identified, no validation details provided.
Study | Country | Focus | Design | Tools | Validated |
---|---|---|---|---|---|
Mukama et al. |
Uganda | Knowledge and attitudes towards cervical cancer (CC) prevention | community-based cross-sectional survey | Questionnaire | No |
Ndejjio et al. |
Uganda | Uptake of CC screening & associated factors | cross-sectional descriptive survey | Semi-structured questionnaire | No |
Azubuike and Unuoha |
Nigeria | Breast cancer (BC) awareness, risk factors, signs & symptoms, preventive measures, attitudes, cure prevention, causes, practices, and associated factors | cross-sectional community survey | Semi-structured questionnaire developed from previous published studies (studies not cited) | No |
Dreyer et al. |
South Africa | School based human papillomavirus (HPV) vaccination & CC knowledge | cross-sectional school based study | Interviewer-administered structured questionnaire | No |
Ali-Risasi et al. |
DRC | Knowledge, attitude & practice about cancer of the uterine cervix | cross-sectional survey | Interviewer-administered questionnaire | No |
Morema et al. |
Kenya | Determinants of CC screening services uptake | cross-sectional survey | Self-administered structured questionnaires | No |
Ahmed et al. |
Nigeria | Knowledge, attitude & practice of CC screening | cross-sectional descriptive survey | Questionnaire (closed & open-ended questions) | No |
Azubuike and Okwuokei |
Nigeria | Level of BC awareness, attitudes and practices towards early detection strategies | cross-sectional descriptive survey | Self-administered semi-structured questionnaire with 23 items developed from previous published studies [studies not cited] | No |
Sudenga et al. |
Kenya | CC: Knowledge, attitudes, practices & perceived risk | cross-sectional survey | Interviewer-administered questionnaire | No |
Irurhe et al. |
Nigeria | Knowledge & awareness of BC | cross-sectional survey | Self-administered questionnaire | No |
Kahesa et al. |
Tanzania | Determinants of acceptance of CC screening | cross-sectional survey | Structured questionnaire | No |
Were et al. |
Kenya | CC screening: Perceptions of risk & barriers | cross-sectional survey | Semi-structured questionnaire | No |
Maree and Wright |
South Africa | Cancer understanding, awareness, and health seeking behaviours | exploratory, contextual, quantitative door-to-door survey | Structured questionnaire | No |
Clegg-Lamptey et al. |
Ghana | BC: late presentation and treatment absconding | cross-sectional survey | Interviewer-administered questionnaire | No |
Osime et al. |
Nigeria | BC knowledge, attitudes and practice | cross-sectional survey | structured self-administered questionnaire | No |
Tebeu et al. |
Cameroon | CC: attitude & knowledge | hospital-based survey | Questionnaire | No |
Ukwenya et al. |
Nigeria | Delayed treatment of symptomatic BC | cross-sectional study | Structured open-ended questionnaire | No |
Kazaura et al. |
Tanzania | Health seeking behaviour among patients with cancer | hospital-based survey | Structured and semi-structured interviews | No |
Kidanto et al. |
Tanzania | CC: Knowledge and attitudes of female patients | comparative cross-sectional survey | Structured questionnaire | No |
Pillay |
South Africa | BC & CC: Awareness | community-based survey | Interviewer-administered structured questionnaire (fixed format) – sample questions included; informed by oncology literature (not specified) | No |
Symptom awareness tools identified, some validation details provided.
Study | Country | Focus | Design | Tools | Evidence of validity |
---|---|---|---|---|---|
Omotara and Yahya |
Nigeria | BC awareness, attitudes and practice | Cross-sectional descriptive community-based study | Interviewer-administered structured validated questionnaire (23 items) | States validated questionnaire, but no further information provided |
Hyacinth et al. |
Nigeria | CC and Pap smear awareness and utilisation | Cross-sectional survey | Validated questionnaire | Referenced an unpublished thesis and one other study which pretested the questionnaire with participants ( |
Oluwatosin |
Nigeria | Rural women’s perceptions of BC and its early detection measures Knowledge of BC and its early detection measures |
Cross-sectional survey | Structured questionnaire with 4 questions & 56 items | Literature, focus groups to refine, test / retest reliability = 0.95; |
Oluwatosin |
Nigeria | BC: Assessment of risk factors and predictive factors for breast examination | Cross-sectional survey | Self-developed three-part semi-structured questionnaire; one section used a validated tool (Gail Model); questionnaire tested for reliability | Test/retest reliability score = 0.95; tested with group of women with similar characteristics to study sample |
Twinomujuni et al. |
Uganda | Understanding the low level of CC screening | Cross-sectional community survey | Semi-structured interviewer-administered questionnaire | Developed from previously published studies and validated tools (articles referenced); estimated Cronbach’s internal reliability = 0.75 |
Akhigbe and Omuemo |
Nigeria | Knowledge, attitudes and practice of BC screening | Cross-sectional descriptive survey | Pre-tested self-administered questionnaire | Pretest; no further details given on pretest process and function of the same |
Kayode et al. |
Nigeria | Knowledge, attitude and practice of breast self-examination | Descriptive cross-sectional survey | Pre-tested structured questionnaire | Pre-tested; no further details given on the pretest process and function of the same |
Shepherd and Mclnerney |
Sierra Leone | BC knowledge | Quantitative descriptive-exploratory design | Questionnaire | Pilot study to test reliability ( |
Obaji et al. |
Nigeria | Awareness and practice of breast self-examination | Cross-sectional descriptive study | Interviewer-administered questionnaire | Validated and pre-tested with a separate sample of women |
Lyimo and Beran |
Tanzania | CC screening: Demographic, knowledge, attitudinal, and accessibility factors | Cross-sectional survey | Structured questionnaire | Pilot testing in similar context, identification and modification of problematic questions |
Mingo |
Botswana | CC: Awareness and screening | Hospital-based survey | Questionnaire | Content validity ( |
Mupepi et al. |
Zimbabwe | Knowledge, attitudes and demographic factors influencing CC screening behaviour | Cross-sectional community survey | Questionnaire | Six focus groups of eight participants each ( |
Kiguli-Malwadde et al. |
Uganda | Knowledge, attitude and practice of women on BC and mammography | Cross-sectional descriptive survey | Interviewer-administered questionnaire | Content validity – questionnaire reviewed for information quality and legitimacy and relevant corrections made |
Mugivhi et al. |
South Africa | Rural women’s knowledge of prevention and care related to BC | Quantitative survey | Structured interview | Pre-tested for validity and reliability ( |
Salaudeen et al. |
Nigeria | Knowledge and attitudes towards BC and breast self-examination | Cross-sectional descriptive survey | Self-administered questionnaire | Pre-tested ( |
Ramathuba et al. |
South Africa | BC knowledge, attitudes and screening practices | Quantitative descriptive cross-sectional design | Closed-ended questionnaire pretested for validity and consistency | Content (literature and peer review) and construct validity; pretest reliability ( |
Okobia et al. |
Nigeria | BC: Knowledge, attitude and practice | Cross-sectional community survey | Interviewer-administered questionnaire | Content validity (literature and expert review) pre-tested for reliability ( |
Francis et al. |
South Africa | Attitudes and knowledge about HPV and CC risk | Brief survey | Questionnaire | Developed based on literature review (articles referenced), pilot tested and revised with a clinic-based population similar to the clinic sample |
Mwaka et al. |
Uganda | Community awareness of CC risk factors and symptoms | Cross-sectional population-based survey | Structured questionnaire | Developed based on literature review (articles referenced) and pilot test |
Symptom awareness tools identified, thorough validation.
Study | Country | Focus | Design | Tools |
---|---|---|---|---|
Naanyu et al. |
Kenya | Lay perceptions of BC in Western Kenya | Cross-sectional survey | BCAM adapted opinions about causes, symptoms, severity and treatment of BC captured as free-text responses to open-ended questions added to the BCAM tool. |
Wachira et al. |
Kenya | Psychometric assessment of BCAM for assessment of BC knowledge and barriers to screening in Kenya | Cross-sectional survey | BCAM: Assessment of face and psychometric validity of BCAM using cognitive testing (and adaptation of some items), factor analysis of survey data and correlations. |
BC, breast cancer; BCAM, breast cancer awareness measure.
Fourteen studies utilised pilot testing
Naanyu et al.
Wachira et al.
Our scoping review provides a synthesis of research
Our findings demonstrate that several tools have been utilised to measure breast and cervical cancer in SSA contexts. SSA countries featured in this review are Botswana,
Twenty of the 41 studies reviewed were on breast cancer. Of these 20, six utilised tools that were not validated,
Our results point to the dearth of comprehensively validated and culturally relevant tools to measure breast and cervical cancer symptom awareness in the SSA context and the need for systematic efforts to develop and validate such tools. These findings are consistent with a study on understanding low cervical cancer screening in Uganda, which noted lack of validated tools in African settings.
Furthermore, validated tools should be culturally relevant for their intended study populations.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
J.M., F.M.W., S.E.S. and A.D.M. initiated the study and developed the study protocol. J.N.G. conducted the literature search, drafted the manuscript, incorporated revisions and prepared the final draft. J.M., F.M.W. and S.E.S. reviewed the articles for eligibility. All the authors reviewed the draft and approved the final manuscript.
This scoping review is part of a project jointly funded by the South African Medical Research Council, MRC UK (via the Newton Fund), GlaxoSmithKline Africa Non-Communicable Disease Open Lab (via a supporting grant Project Number: 023), University of Cape Town and the Cancer Association of South Africa.
This research is linked to the CanTest Collaborative, which is funded by Cancer Research UK [C8640/A23385], of which Fiona M. Walter is Director. The funders had no role in the study design, data collection or decision to publish. Authors retained control of the final content of the publication.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views expressed in the submitted article are those of the authors and not the official position of any of the funders or institutions represented.
List of potential search terms from existing literature.