Introduction

Breast cancer is a leading global health problem. There were 2.1 million cases diagnosed in 2018, and 627,000 died of breast cancer globally [1, 2]. Among women, it is the most commonly diagnosed cancer and the leading cause of cancer deaths. The mortality to incidence ratio of breast cancer in low-income countries (LICs) is three times higher than in high-income countries [2]. This highlights the increasing burden of breast cancer in LICs. Moreover, the incidence of breast cancer is increasing in LICs due to physical inactivity, changes in reproductive patterns, and unhealthy dietary habits [3, 4].

Breast cancer screening is an effective prevention strategy to reduce breast cancer burden [5]. Mammography (MMG), clinical breast examination (CBE), and breast self-examination (BSE) are three widely practiced screening tests. MMG is recommended as a standard screening test globally [5]. However, considering the cost-effectiveness, CBE, and BSE are also recommended for low-resource settings [6–8]. Early detection of breast cancer saves lives, preserves the quality of life, and prevents catastrophic out-of-pocket payments [9, 10]. In addition, early diagnosed cases can be successfully treated with less extensive breast conservative surgery [11].

However, the late presentation of breast cancer is still common, and it has worsened the economic and health conditions of LICs such as Nepal [12, 13]. Majority of women in LICs tend to seek medical treatment in the late stages of cancer [14]. According to a clinical study conducted in Nepal, most breast cancer patients sought treatment at late stages (stages II and III) with an average tumor size of two to five centimeters [15]. This delay has led to increased tumor size, complicated treatment, and finally, premature mortality in Nepal [16–18]. Further, the absence of universal health coverage adds a substantial financial burden to the patients and their families [19, 20].

Considering these detrimental consequences of breast cancer, it is necessary to identify factors associated with low screening intentions. So far, different reasons have been identified for low screening intentions, such as lack of education, absence of family history, poor access to screening, financial difficulties, and fear [21, 22]. However, a great part of variance remained unexplained due to the inclusion of limited factors in those studies [23]. This study builds on previous research by including relevant factors based on the concept of the theory of planned behavior (TPB), perceived susceptibility, perceived severity, and fatalism [23].

Furthermore, studies on breast cancer screening intention and behavior are limited in LICs. Therefore, this study aimed 1) to examine breast cancer screening behavior among women in Kathmandu Valley, Nepal, and 2) to identify the factors associated with the intentions to perform breast cancer screening tests (MMG, CBE, and BSE).

Methods

Results

Out of 529 women who were approached for this study, 500 agreed to participate. There was no missing data and all data from the 500 participants were analyzed in this study. Table 1 summarizes the socio-demographic characteristics of the women included in this study. The mean age of women was 48 years (standard deviation [SD] 5.5, range 40–69). Of the total, 18.0% had an education level of bachelor’s degree and above. The median monthly family income was Nepalese Rupee (NPR) 47,500 ranging from NPR 825 to NPR 298,397. Of the total, 44.8% were housewives. Around 20% of women had a family history of breast cancer. Of the total, 37.4% had family members from the health field (students or professionals). Only 15% of the women participated in the awareness program related to breast cancer.

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Table 1. Socio-demographic characteristics of participants (n = 500).

https://doi.org/10.1371/journal.pone.0245856.t001

Table 2 shows a summary of the exposure variables. Among all variables, the mean score of perceived susceptibility towards breast cancer was the lowest with a score of 2.5 (SD 1.0).

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Table 2. Summary table of exposure variables.

https://doi.org/10.1371/journal.pone.0245856.t002

Table 3 illustrates the practice of breast cancer screening. Of the total, 3.4% of women had undergone MMG biennially, 7.2% had undergone CBE annually, and 14.4% practiced BSE monthly. Similarly, Table 4 shows the breast cancer screening intention. Around 20% of women expressed strong intention (strongly agree) to undergo BSE. More than half (64.6%) of women disagreed of having the intention to undergo MMG.

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Table 3. Breast cancer screening behavior (N = 500).

https://doi.org/10.1371/journal.pone.0245856.t003

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Table 4. Breast cancer screening intention (N = 500).

https://doi.org/10.1371/journal.pone.0245856.t004

Table 5 shows the result of the multivariable partial proportional odds model of the factors associated with breast cancer screening intention. After adjusting for confounders and other variables, women who participated in the awareness program of breast cancer were more likely to have the intention to undergo MMG (AOR = 2.69, 95% CI 1.42–5.11).

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Table 5. Factors associated with breast cancer screening intention (N = 500).

https://doi.org/10.1371/journal.pone.0245856.t005

Women who perceived themselves susceptible to breast cancer were more likely to have the intention to undergo MMG (AOR = 1.06, 95% CI 1.01–1.12) and CBE (AOR = 1.08, 95% CI 1.03–1.13). In contrast, women with high fatalistic beliefs were less likely to have the intention to undergo CBE (AOR = 0.92, 95% CI 0.86–0.99).

For MMG, women with a positive attitude towards MMG (AOR = 1.40, 95% CI 1.19–1.65), higher subjective norms (AOR = 2.18, 95% CI 1.81–2.62), and high perceived behavioral control (AOR = 1.96, 95% CI 1.65–2.34) were more likely to have the intention to undergo MMG.

Similarly, women who had positive attitudes towards CBE (AOR = 1.25, 95% CI 1.11–1.41) and had higher subjective norms (AOR = 1.64, 95% CI 1.43–1.89) were more likely to have the intention to undergo CBE. Having a higher perceived behavior control was associated with the likelihood of being in a higher agreement level (A and SA) to undergo CBE as opposed to being at neutral or below neutral level (AOR = 1.55, 95% CI 1.24–1.95). The effects became much stronger with increment in perceived behavior control, further, the largest effect was identified among the final level (i.e. SA versus A, N or SD&D).

In the case of BSE, women with higher attitude (AOR = 2.91, 95% CI 2.13–3.99), and those with better subjective norms (AOR = 1.68, 95% CI 1.19–2.37) were positively associated with increased odds of expressing higher agreement (A and SA) to undergo BSE rather than expressing neutral or disagreement. Women who had high perceived behavioral control were more likely to have intention to undergo BSE (AOR = 2.11, 95% CI 1.69–2.62). Findings revealed that having better knowledge of breast cancer increased the odds of a woman expressing higher agreement to undergo BSE rather than expressing neutral or disagreement (A and SA versus N, D&SD; AOR = 1.18, 95% CI 1.08–1.29), though it failed to achieve statistical significance in other categories.

Discussion

All three components of TPB (Attitude, subjective norms, and perceived behavior control) were positively associated with the intention to undergo MMG, CBE, and BSE. Similarly, women who perceived themselves susceptible to breast cancer were more likely to have the intention to undergo MMG and CBE. Women who participated in the breast cancer awareness program were more likely to have the intention to undergo MMG. In contrast, women with fatalistic beliefs were less likely to have the intention to undergo CBE. Furthermore, with an increase in knowledge of breast cancer, women were more likely to have the intention to undergo BSE.

Our study findings align with the previous studies that have used TPB to predict different screening and healthy behavior intentions [45–47]. In our study, women were more likely to have the intention to undergo screening tests when they had a positive attitude towards a particular test. Positive attitude was found as an important factor to change behavior like adopting a healthy lifestyle [48]. People intend and are motivated to do such behavior which they believe can lead to positive outcomes [49]. Furthermore, in our study, women receiving screening suggestions from their family members and close ones were more likely to have intention to do it. People usually adhere to the advice given by trusted family members and close ones [50]. Social ties were found to have a positive influence in bringing healthy changes among participants in different settings [51–53]. Therefore, educating a person alone is not sufficient; the involvement of friends and family (social network) is also salient to effectively promote screening intention. It is particularly important for countries like Nepal, where women need permission from their husbands and in-laws before making any personal decision or health choices [54–56].

Likewise, screening intention was higher among women who believed in their capability to go for screening and perceived fewer barriers to screening. Similar to our finding, in a study conducted among Latina women in the United States, women expressed greater intention of receiving cervical cancer screening tests when they had high perceived behavior control [57].

It is worth considering particularly in low and middle-income countries like Nepal where screening services are not easily available. Many women are not financially competent to afford expensive services like MMG. Women should be involved in income-generating activities where they could support their expenses. Besides, a screening test like BSE can be done by a woman herself under complete privacy and autonomy. Proper training and awareness must be provided so that women perceived control to undergo those screenings which are free of cost and can be done independently. Evidently, in our study women who had high knowledge of breast cancer were more likely to have the intention to undergo BSE.

Another factor associated with the intention to undergo screening was perceived susceptibility. Women were more likely to have the intention to undergo MMG and CBE when they perceived themselves susceptibility to breast cancer. This is also an important factor to be considered particularly for low and middle-income countries like Nepal where people seek services only when they perceive themselves susceptible to health risks [58, 59]. Women did not perceive the need of undergoing screening until they had recognizable symptoms of breast cancer [60]. As a result, victims end up facing multiple challenges associated with late presentation, treatment difficulties, financial cost, etc. It is pivotal to make people realize that anyone can suffer from breast cancer and their timely screening practice can prevent them from other detrimental consequences. Conducting an awareness program is therefore key to promote screening behavior such as MMG which needs a more conscious decision. Evidently in our study, women who had participated in the awareness program were more likely to have the intention to undergo MMG. In our study intention to undergo BSE was not associated with perceived susceptibility. This could be because people usually prefer to seek help from health professionals when they actually perceived some kind of health threat.

Like perceived susceptibility, fatalism is a potential barrier preventing people from participation in health-promoting behaviors [61]. However, in our study, the fatalistic belief was associated with the intention to undergo CBE only. Women with high fatalistic beliefs were less likely to have the intention to undergo CBE. Previous studies have also presented the mixed result of fatalism in screening intentions [62, 63]. Therefore, there is a need for an in-depth exploration of this belief before making any concrete conclusion. Nonetheless one of the reasons for our findings could be because women in a religious country like Nepal are usually reluctant to show their private body parts to anyone including health professionals unless it is very essential. Unlike BSE (which is self-examination) and MMG (test conducted using a device), CBE is the manual palpation done by the health care professionals. Considering the nature of the test, women with religious and fatalistic beliefs might be reluctant to pursue it [64, 65]. Therefore, deep traditional and fatalistic beliefs should not be ignored while designing screening interventions.

This study has several limitations. First, women might have over-reported their intention to undergo and behavior of screening to avoid awkwardness due to further questioning on their intention and behavior. However, the chance of over-reporting is equal for all participants, so the association between the exposure variables and the outcome variables should not be affected by this bias. The study was conducted in the urban areas of Nepal. Therefore, it cannot be generalized to the entire population. However, urban areas were selected considering the availability and accessibility of the screening tests. Finally, women who did not agree to participate in this study might have a different attitude, fatalistic belief, and knowledge level, which is not reflected in this study.

Despite these limitations, this study provides a comprehensive understanding of different factors associated with breast cancer screening intention. This could be helpful to develop a culturally sensitive intervention to promote breast cancer screening in resource-limited settings. This study also provides information on breast cancer screening behaviors, knowledge level, and fatalistic beliefs of women towards breast cancer. Findings can pave a way for future studies on breast cancer screening behavior.

Conclusion

This study revealed poor screening behavior of women living in Kathmandu Valley, Nepal. Findings highlight the importance of TPB (positive attitude, subjective norms, perceived behavior control) along with perceived susceptibility and fatalism in increasing intention to undergo screening tests. Thus, educating only an individual is not enough, the inclusion of family members and addressing deep fatalistic beliefs are crucial for the successful promotion of screening. Women should be encouraged to undergo screening timely even before the appearance of symptoms. Meanwhile, screening tests should be made available and approachable before advocating for those services. Most importantly, practical training on BSE should be provided so that women feel competent to carry out themselves. To conclude, multidimensional culturally sensitive interventions are necessary to promote breast cancer screening in Nepal.

Supporting information

Acknowledgments

We would like to express our gratitude to all the women who participated in this study. We are grateful to every health professional, professors, local leaders, and experts for their contribution to questionnaire review and support during data collection. We would also like to thank Nepalese organizations and communities for their support and encouragement.