Breast Cancer Screening Barriers from the Womans Perspective : a Meta-synthesis

Nowadays cancers are leading cause of death around the world (Aghbali et al., 2013) Breast cancer (BC) is one of them with increased incidence, high mortality rate, and high economic and social costs (Zainal et al., 2013). The BC stands for about 30% of cancer-caused deaths in High Income Countries Breast cancer is about 30% cause of cancer deaths in High Income Country. And about 29% of all cancer incidences is also reported to be 29% of all cancer incidences (Al-Dubai et al., 2012). In 2009 there were approximately 192,000 new diagnoses of BC and 47,000 deaths in the USA. BC ongoing to be a major public The BC is going to be a major public health problem in High Income Countries as well as the Low Income ones (Yusuf et al., 2013). Lifestyle behaviors such as lack of exercise, fatty diet, and breastfeeding habits have been mentioned as some of the risk factors of the BC (Berkiten et al., 2012). Previous studies demonstrated that the


Introduction
Nowadays cancers are leading cause of death around the world (Aghbali et al., 2013) Breast cancer (BC) is one of them with increased incidence, high mortality rate, and high economic and social costs (Zainal et al., 2013). The BC stands for about 30% of cancer-caused deaths in High Income Countries Breast cancer is about 30% cause of cancer deaths in High Income Country. And about 29% of all cancer incidences is also reported to be 29% of all cancer incidences (Al-Dubai et al., 2012). In 2009 there were approximately 192,000 new diagnoses of BC and 47,000 deaths in the USA. BC ongoing to be a major public The BC is going to be a major public health problem in High Income Countries as well as the Low Income ones (Yusuf et al., 2013). Lifestyle behaviors such as lack of exercise, fatty diet, and breastfeeding habits have been mentioned as some of the risk factors of the BC (Berkiten et al., 2012). Previous studies demonstrated that the studies is often limited by small sample sizes (Alizadeh, et al., 2013). In this regard the aim of this study was to conduct a systematic review of qualitative studies to explore the barriers of BC screening from women's perspective.

Materials and Methods
This study is a meta-synthesis that has been designed and conducted with the aim of systematically exploring qualitative studies for identifying the barriers to appropriate BC screening. The data have been collected in the first stage using these search keywords: "breast cancer", "breast cancer screening", "breast cancer detection", "breast cancer prognosis" and their Persian equivalents. Then in the next stage combining keywords: "barrier", "qualitative study", "qualitative" in the SID, Iranmedex, PubMed, Google Scholar, Ovid, Scopus, and Cochrane Library databases. No time limitations were considered for searching and selecting the articles. The inclusion criteria for the study were: conduction of the study as a qualitative study, analysis of barriers from women's perspective, and articles published in Persian and English. The exclusion criteria were: studies presented in seminars and conferences, educational studies, analysis of barriers from a point of view other than the women's, analysis of barriers from the point of view of women who had physical problems (such as multiple sclerosis, ambulatory impairments). For identification and coverage of more published articles, after searching the databases, some valid journals in this field also were hand searched. To increase confidence of identification and analysis of the articles, after selecting the main articles and deleting the articles with poor eligibility, the reference lists of the selected articles were also searched. Out of 2134 related articles found, after deletion of articles with poor relation to the study aims, eventually 21 thoroughly related articles were included and accurately studied ( Figure 1). After accurately studying and extracting the needed data, the extracted data were first summarized in the extraction table and thematically analyzed. Excel 2007 software was used to draw graphs. The Endnote X5 software was used for organizing, title and abstract reviewing and also identification of duplicated articles (Sadeghi-Bazargani, Tabrizi et al., 2014).
In order to assess the quality of the selected articles, Critical Appraisal Skills Programme (CASP) assessment tool was used. This tool consists of 10 questions for exploring principles, hypotheses, and specificities of qualitative studies and systematically helps to understand and recognize issues reviewed in qualitative studies. The first two questions are for screening and can be readily answered. If the answer to both of the questions was "yes", assessment of the article continued. A four point scale was used for each criterion ranging from 1 to 4 which include: 1 (totally disagree), 2 (disagree), 3 (agree), 4 (totally agree). The given point demonstrates the success of the article in reaching the intended criterion (in the checklist).
Whenever we were confident that the intended criterion was completely reached, "totally agree" choice was selected.
Whenever we were sure that the intended criterion was not reached at all, or if there was no information about that criterion, the "totally disagree" choice was selected.
If we were doubtful whether or not the intended criterion is reached; for example because the presented information was vague, or because the intended criterion was reached only in some aspects, one of the "agree" or "disagree" choices had to be selected and the selection depended on the reviewers' decision about the amount of adherence to the required criterion. The minimum and maximum score of each article were 8 and 32. To make easier the comparison of the quality of the articles, the scores 8 to 16 were considered as "C", 17 to 24 as "B" and 25 to 32 as "A". (The results of articles' assessment is included in appendix 1)

Results
In this study from among 2134 found related articles, eventually 21 articles totally relevant to the aims of the study were included and reviewed thoroughly. The characteristics of the reviewed articles are brought in table 1. Most of the studies were conducted in USA (8 articles) and Iran (3 articles). In the 21 selected articles attitudes of 1084 women (approximately 52 participants on average for each study) about screening barriers were reviewed.
Using Thematic Analysis, the similar cases were combined and the barriers that extracted from the studies categorized and then organized in 10 groups which are shown in figure 1 according to their recurrence in the studies.

Lack of knowledge
Lack of knowledge about the breast cancer screening, oblivion of the existence of screening services and the way to use them, wrong information and knowledge about screening and getting information from unaware people who caused patients' misleading, were the most important barriers relating to breast cancer screening in the field of women's knowledge.

Lack of access
Most problems related to access were: financial, geographic and transportation, cultural, and timerelated (due to lack of time for attending screening) problems.

Fear
Fear of the result of screening to be positive, and fear of pain were the most common aspects of fear of breast cancer screening.

Professionals' attitude
In some studies women had indicated that the professionals and other health service providers have told them that "there is no need for screening". Also in some studies the participating women had mentioned that the health service providers do not inform them about screening and that most of them consider treatment as their first priority rather than prevention.

Patients' beliefs
Women's false beliefs were also of the most important barriers of screening. The most prominent of those beliefs were: false religious beliefs (fatalism), believing that screening has no efficacy, preferring local and conventional curers, lack of fear, believing that the disease would diffuse when touched, and cultural limitations.

Procrastination
In some studies, participants had mentioned procrastination due to carrier and life avocations, lack of fear, and low screening culture, as the breast cancer screening barriers.

Embarrassment
Most women (especially in Islamic and developing countries) had   22=B *reference in table1; *** Score each item; ** Continue (If the answer to both questions was "yes", assessment of the article continued); **** Total score (C= 8 to16, B= 17 to 24, A= 25 to 32)     embarrassment as a reason for not participating in screening programs. This case was seen more frequently when the professional was male.

Long wait for getting an appointment
Long wait for an appointment was mentioned as an important reason for refusing or postponing participation in screening.

Language barriers
This problem was seen in women who lived abroad or in multilingual countries in which the health providers talked in a different language, because it causes the women not to be able to obtain the required service.

Negative experiences
Negative experiences from past screenings (due to pain, inappropriate services, bad behavior or any other reason) were mentioned as an screening barrier.
Purposive sampling with 8-time recurrence was the most frequent kind of sampling among the studies. In 17 studies the used approach in qualitative studies wasn't mentioned. Focus Group Discussion was mentioned in 9 papers, semi-structured interviews were mentioned in 6 papers, and in 6 studies both methods were used. In 6 studies content analysis method was used. Using two coders in 9 studies and respondent validity in 5 studies were the most frequently used methods to provide rigor and accuracy in results. In 15 studies justification was obtained from ethics committee and in 14 studies written consensuses were filled by the participants. Studies' assessment results showed that the assessment score for studies was 68.91 from 100. In 3 studies from 21 papers the assessment was not continued, because the answer to at least one screening question was "no". Maximally scoring parts were "data collection" and "ethical issues" and the minimum score related to "feedback".

Discussion
Identification of the screening barriers will have important role in prevention of disease progression. For identification of screening barriers from women's perspective, qualitative studies' methods could have the greatest efficacy; however, the results of these studies are not generalizable to the bigger society and other regions. So In this study with an approach of systematically reviewing the results of these studies in the field of identification of breast cancer screening barriers from the women's perspective, we tried to summarize and report the breast cancer screening barriers. The results showed that lack of knowledge, lack of access (financial, geographical and time-related), fear, beliefs of health service providers especially in the field of breast cancer, and beliefs of women themselves are the most important screening barriers from women's perspective.
Lack of knowledge and awareness, with a recurrence of 15 out of 21 studies was one of the most important breast cancer screening barriers from women's point of view that is in accordance with the results of previous studies in this field (Al-Naggar and Bobryshev 2012; Beshir and Hanipah 2012;Guvenc et al., 2012). Therefore scheduling and implementation of effective interventions to increase awareness and knowledge of women especially in rural and deprived regions seems to be an important affair. For this goal, special methods and educational templates regarding environmental conditions and audiences must be used such as group education by national and regional media, group discussion sessions, publication of educational material in the form of booklets, pamphlets and posters, education by the health service providers especially in the premier level of the service provision, education by peer levels, and etc.
Lack of access was also one of the most important barriers to breast cancer screening from women's point of view which consists of financial, geographical, and cultural access problems pointed out by most of the studies (Noroozi and Tahmasebi 2011;Park et al., 2011;Roder et al., 2013). Therefore making practical attempts to reduce screening costs and to insure these services, to increase women's geographical access by expanding centers and clinics providing these services in far and deprived locations and to provide these services by the primary care providers, and also to increase cultural access by service being provided by female practitioners or other female service providers, providing a private place in which the clients could feel convenience and safety and also attempts to produce culture of using these services, are recommended.
According to the study results, fear of positive result of screening and fear of pain of some screening methods were among the most important barriers to screening. Results of previous studies also showed that fear of screening is a major breast cancer screening barrier (Bener et al., 2009;Ahangar et al., 2014). However, results of some studies indicate that sometimes fear can be both a barrier and an encouraging and facilitating factor for breast cancer screening (Abdollahzadeh et al., 2014). Therefore to eliminate women's fear and to cause them to participate in screening and to increase screening participation rate, warning women about sequences of late detection of breast cancer and using painless methods, can be effective ways.
From the women's perspective, health service providers in the field of breast cancer have a prominent role in participation of target group in screening. For many of them have reported that doctors and other service providers have told them that "screening is not needed" or that most of the professionals prefer treatment over prevention, so it seems that beliefs and actions of health providers has a great impact on women's participation in screening; this has been shown in previous studies also (Karadag et al., 2014). For this reason changing the attitude of the health providers seems to be necessary. To do this, changing payment methods from salary or other methods to capitation method can increase amount of screening, because with this method, health service providers will prioritize prevention over treatment because if the covered person becomes ill and gets referred to higher levels of healthcare system, and surgeries and other hospital cares, then the doctor will have to pay the costs and so his/her revenue will decrease.
Results showed that besides the beliefs of health providers, some beliefs of women are also effective in participation in screening. Among these beliefs we can refer to false religious beliefs (fatalism) which is manifested by saying "I trust in god" or "whatever god wants", not believing in efficacy of screening and its role in prevention and treatment, confidence in local and conventional curers, believing that the disease will diffuse if tampered with and cultural limitations such as women's role, fear of husband, and sexual issues; mostly seen in developing countries and socially and culturally retarded societies. Results of some previous researches conducted in this field also indicate these barriers. Therefore endeavor to change false religious beliefs, development of prevention culture, cooperation with local and conventional curers, and also trying to eliminate cultural barriers to improve the cancer screening condition seem to be promising methods.
Regarding the results of the current study, the most important barriers besides the barriers already discussed are: procrastination, embarrassment, long wait for getting an appointment, language barriers, and previous negative experiences that are indicated in various studies (Feng et al., 2014;Floriano et al., 2014). To surmount these barriers we recommend: identification of high risk women and their follow-up to prevent procrastination, providing private service places and appropriate time for service provision to solve the embarrassment problem, management of health service providers having the same language with people, providing the women with translators or teaching the native languages to the service providers to eliminate the language barriers, and presentation of good quality services and appropriate behavior with the patients to prevent negative screening experiences.
The main limitation of the present study is the low amount of the results to the qualitative studies. Therefore it is recommended that another review study be conducted including other types of studies. Another limitation of the study was that our search was limited to only English and Persian languages which may result in bias.
In conclusion: the current study has summarized and reported the barriers of breast cancer screening, by systematically reviewing the qualitative studies. According to its results, increasing women's awareness, reducing screening service costs, increasing and developing screening service provision centers, promote culture of screening, presenting less painful screening methods, changing the beliefs of health service providers and the women, providing places with privacy for provision of services, reducing the waiting time for appointments, removing language barriers, and providing high quality services and appropriate behavior, are necessary. Results of this study could be used by managers and health service providers especially in the field of cancer, in planning and implementing interventions in order to improve the breast cancer screening conditions.