Title: Socio-cultural beliefs and perceptions that influence diagnosis and treatment of breast
cancer among women in Ghana: evidence from a mixed methods systematic review
Version: 1 Date: 29 Jul 2023
Reviewer:  Easter Chukwudi Osuchukwu
Reviewer's report:
The article was well written, aboveall, following some adjustment would enhance it fit for
publication;
Introduction section
In 2020, it was estimated that 2.3 million breast cancer cases were newly diagnosed with 685,000
deaths worldwide [1]."
Comment: The sentence lacks clarity in its presentation and could benefit from rephrasing for
better readability.
"Evidence from previous studies shows that cultural factors such as conceptualizations of health,
illness, beliefs, and values do influence the breast cancer screening practices of women in certain
populations [4-6]."
Comment:  The sentence is lengthy and could be improved for better clarity and conciseness.
"Breast cancer screening is reported to be relatively low among women living in Ghana."
Comment:  The statement is clear but could be made more engaging or specific.
"Although there is a low level of awareness and knowledge about breast cancer among women
in Ghana which appears to be a major barrier to breast cancer screening, there is also a lack of
understanding of the perceptions and beliefs toward breast cancer diagnosis and treatment."
Comment: The sentence is quite long and contains multiple ideas. It could be broken down or
restructured for better readability.
"Culture is considered a multidimensional set of shared beliefs and socially transmitted
ideologies about the world, which are passed on from generation- to generation [9, 10]."
Comment: The sentence is clear but could be improved for conciseness.
"Cultural beliefs within certain communities are considered a determinant of health risk
perceptions and behaviors in promoting or seeking health care in diverse populations [11]."
Comment: The sentence is clear, but it could be more specific about which diverse populations
it refers to.
"In most Ghanaian communities breast cancer is believed to be associated with supernatural
powers, hence women seek alternative treatments (healing/prayer camps) first and only report
to health facilities in advanced stages of breast cancer [15]."
Comment: The sentence is understandable, but it could benefit from rephrasing to improve the
flow and clarity of ideas
Method section
"Scoping reviews are conducted to map essential concepts and are used to gather evidence in
research areas that have not been previously reviewed comprehensively [18]."
Reviewer comment: This sentence provides a general statement about the purpose of scoping
reviews. It would be helpful to specifically state how this scoping review contributes to the
existing literature and what knowledge gaps it aims to address.
"Inclusion and exclusion criteria
Adopting the JBI guidelines [16], the inclusion and exclusion criteria for the review are
categorized in terms of population, concept, context, and sources (Table 1)."
Reviewer's comment: The inclusion and exclusion criteria are mentioned, but it's essential to
include Table 1 to provide a clear and concise overview of these criteria. The table can be used
to list the specific criteria for population, concept, context, and sources.
"Following the searches, the identified records were exported into EndNote 2020 reference
manager for duplicate removal."
Reviewer's comment: It's good to mention that duplicate removal was performed, but please
provide more information on how many records were identified initially and how many
duplicates were removed.
"After the duplicate removal, the reviewers ensured consistency in screening through the
following process: (1) joint screening by two reviewers was conducted until they felt confident
to start independent screening, (2) independent blinded screening of titles/abstracts followed
by a meeting and discussion to discrepancies and (3) repetition of step 2 until an acceptable
agreement was met."
Reviewer's comment: This screening process is described well, but please clarify how many
reviewers were involved in the joint screening and how many rounds of step 3 were conducted
to reach an acceptable agreement.
"The first step involved three reviewers who screened all the articles identified after the titles/
abstract screening."
Reviewer's comment: It is not clear why three reviewers were involved in the first step of
screening, and the rationale for this approach should be explained.
"A convergent synthesis design was employed to transform the data into narrative form because
the extracted information was from quantitative, and qualitative studies. This method was
employed to achieve the objective of the study."
Reviewer's comment: The term "convergent synthesis design" requires further explanation, as
it's not a widely known approach. Please provide a brief description of what it entails and why
it was chosen for this scoping review.
"Our search yielded a total of 176 records from the electronic databases. After duplicates were
automatically removed through the EndNote (n=76), 100 records were reviewed independently
by three authors based on the title and abstract. Records that did not meet the inclusion
criteria were removed after holding discussions to identify discrepancies in the review process.
Thereafter full texts of the remaining 25 articles were assessed for eligibility. Hand-search of
the included study references yielded no results. In total, we included 15 studies [20-34]. The
article selection process is shown in the PRISMA flow diagram (figure 1)."
Reviewer's comment: The methodology for the literature search is well-described, but it would
be helpful to provide additional details on the inclusion and exclusion criteria applied during
the full-text assessment of the 25 remaining articles. Additionally, please consider mentioning
the specific reasons for excluding the 85 articles from the initial 100 that were not included in
the review.
Results
"The majority of the studies [20-22, 24-33] were conducted in the southern part of Ghana. Eight
of the included studies were qualitative while the rest were quantitative in design. The summary
of the characteristics of the 15 studies is shown in Table 2."
Reviewer's comment: It is essential to discuss the potential implications of the geographical
concentration of studies in the southern part of Ghana and how this might affect the
generalizability of the findings to other regions of the country. Additionally, please provide more
information about the specific research questions addressed by the qualitative and quantitative
studies to better understand their contributions to the review.
"Breast cancer is believed by some sections of Ghanaians to be a curse or a punishment from
the lesser gods for sins committed by the individual [20]. Some women believe that an extra-
marital immoral lifestyle provokes God’s retribution for breast cancer development [27]. Some
people believe that it is an ancestral punishment for the woman’s refusal to give birth in order to
continue the ancestral lineage [21] and because of this, they are given spiritual babies to suckle
the breast which then causes cancer [21]."
Reviewer's comment: The cultural beliefs section provides valuable insights into the perceptions
of breast cancer in Ghana. However, it would be beneficial to add some context on the prevalence
of these beliefs and whether they are specific to certain regions or communities within the
country. Additionally, please consider discussing the potential impact of these beliefs on breast
cancer diagnosis and treatment-seeking behaviors in Ghanaian women.
"A participant narrated:
'I believe my condition is spiritual and I realized it is coming from my mother's side' [29].
'The problem is that my disease is a spiritual attack, so it has to be treated spiritually; the hospital
drugs cannot get this out of me…' [34]."
Reviewer's comment: It is valuable to include direct quotes from participants to illustrate their
beliefs and experiences. However, to maintain confidentiality and anonymity, consider using
pseudonyms or other identifiers instead of direct quotations. Additionally, please elaborate
on how such spiritual beliefs might influence treatment decisions and access to conventional
medical care.
"Some women perceived that breast cancer is caused by spider bites [22], hereditary, extreme
stress [20, 30] trauma, infections [20] diet, or lifestyle [20, 33]. Some perceived risk factors
of breast cancer as stated by some women included non-breastfeeding women, obesity, or
overweight [23, 28, 31], and contraceptive use [28]. Some women had the perception that
male health practitioners would not be allowed to examine or see their breasts while some
preferred male doctors to examine their breasts [25]. A study in Accra conducted among female
nonmedical students revealed that suckling the breast by a male caused breast cancer [26]. It is
also perceived that putting money in the brassieres could be a possible cause of breast cancer
among females [21, 33]. A study by Iddrisu et al and Agbokey revealed that breast cancer is a
disgraceful disease, dangerous, and a fast killer [21, 29]. Some people also believe that breast
cancer can be cured [25, 30] by herbal treatment or medicine [23] while some believe that it is
not curable [25]. Some people also believed that breast cancer was contagious and transmissible
and avoided sharing equipment with breast cancer survivors [29]."
Reviewer's comment: The section on misconceptions about breast cancer provides important
insights into the knowledge gaps and potential misconceptions among the Ghanaian population.
However, it would be beneficial to discuss how these misconceptions might impact breast cancer
awareness, early detection, and treatment-seeking behaviors in Ghana. Additionally, consider
discussing any efforts made by public health organizations or healthcare providers to address
these misconceptions and improve breast cancer education in the country
Discussion Section
"This study reviews the existing literature on sociocultural beliefs that influence the timely
diagnosis and treatment of breast cancer among women, and this revealed diverse cultural,
spiritual, and religious beliefs across the regions of Ghana."
Reviewer's comment: The opening sentence of the discussion provides a clear overview of
the study's scope and findings. However, it would be beneficial to briefly mention the main
implications or potential impact of these diverse beliefs on breast cancer diagnosis and treatment
outcomes in Ghanaian women.
"Consistent with study findings in SSA [12] it is believed that breast cancer emanates as a result
of supernatural forces, curses, and punishment from lesser gods/ancestors for wrongdoings.
Though not all Africans hold this traditional belief in ancestral spirits, some believe that health
and illness are in the hands of a higher power such as God or Allah [12]."
Reviewer's comment: The reference to SSA (Sub-Saharan Africa) is informative, but it would
be helpful to clarify what "study findings in SSA [12]" are being referred to in the context of
breast cancer beliefs. Additionally, it could be valuable to expand on the potential implications
of these supernatural beliefs on breast cancer care-seeking behavior and how they might interact
with modern medical practices in Ghana.
"Due to the cultural/traditional belief systems and practices, most women report to health
facilities with advanced stages of breast cancer which impacts the breast cancer diagnosis and
treatment."
Reviewer's comment: The sentence highlights a crucial point about the impact of cultural beliefs
on the delayed presentation of breast cancer cases. To strengthen the discussion, consider citing
specific studies or data from the literature review that support this claim and elaborate on the
potential consequences of delayed diagnosis on treatment options and patient outcomes.
"Religious fanaticism coupled with lack of knowledge about the disease condition could impede
the utilization of medical treatment, especially when religious beliefs impact negatively on
people’s health-seeking behaviors."
Reviewer's comment: The statement draws attention to the negative impact of religious
fanaticism and lack of knowledge on medical treatment utilization. However, it would be
beneficial to provide more specific examples or evidence from the included studies that illustrate
how religious beliefs hinder health-seeking behaviors related to breast cancer, and how these
challenges might be addressed to improve early detection and treatment.
"This review identified varied perceptions of breast cancer where breast cancer has been
attributed to spider bites, putting money in the brassieres among others. Some believed that
breast cancer was a contagious and transmissible disease. These findings show poor knowledge
level among women concerning breast cancer."
Reviewer's comment: The highlighted text succinctly summarizes some of the key
misconceptions and misconceived beliefs about breast cancer in Ghana. To enhance the
discussion, consider elaborating on the potential consequences of these misconceptions on breast
cancer screening rates, treatment adherence, and overall health outcomes for affected women.
It would also be valuable to discuss potential strategies for addressing these misconceptions
through targeted education and awareness campaigns.
"Even though in this review most women had heard or were aware of breast cancer, the varied
perceptions about breast cancer suggests low knowledge level of breast cancer."
Reviewer's comment: The statement raises an important point about the disparity between
awareness and knowledge levels about breast cancer among Ghanaian women. It would be
helpful to discuss the potential reasons for this disconnect and explore ways to bridge the gap
between awareness and accurate knowledge about breast cancer in the population.
"The low knowledge level of breast cancer among women have been associated with late
presentation of breast cancer to health facilities. Women presenting to health facilities with
advanced stage breast cancer have been associated with low survival rate in the African region
as compared to high income countries. A study conducted in Ghana revealed that the breast
cancer survival rate among women was below 50% which was probably due to late presentation
and lack of breast cancer screening."
Reviewer's comment: The highlighted text effectively highlights the significant impact of low
knowledge levels on the late presentation of breast cancer and subsequent survival rates in
Ghanaian women. To reinforce this point, consider citing more specific studies or data from
the literature review that support the association between knowledge levels, late presentation,
and survival rates. Additionally, discuss potential interventions or strategies to improve breast
cancer awareness and early detection in the Ghanaian context
Conclusion section
"Metaphors such as spider bites, supernatural forces, witchcraft, and many other beliefs are
associated with breast cancer in Ghana which impact the understanding of the disease and
whether to seek medical treatment."
Reviewer's comment: The highlighted text effectively emphasizes the influence of cultural
beliefs and metaphors on breast cancer understanding and healthcare-seeking behaviors in
Ghana. It would be valuable to include specific examples or quotes from the included studies to
illustrate the prevalence and impact of these metaphors on breast cancer management.
"Therefore, culturally sensitive intervention programs targeted at improving breast cancer
awareness among women, religious and traditional leaders is imperative."
Reviewer's comment: The statement highlights the importance of culturally sensitive
intervention programs to improve breast cancer awareness. To strengthen this point, consider
providing some examples of what these intervention programs could entail, such as community
engagement, workshops, or educational materials tailored to address specific cultural beliefs
and misconceptions.
"Taking into consideration the diverse cultural and traditional beliefs about breast cancer, there
is a compelling need for nationwide public education on breast cancer to clarify the myths and
misconceptions about the disease."
Reviewer's comment: The highlighted text raises a crucial point about the need for nationwide
public education on breast cancer. It would be beneficial to discuss how such education programs
could be effectively designed and implemented, considering the cultural diversity within Ghana
and the varying beliefs in different regions.
"It is important that considerations are given to these issues, not only focusing on how these
issues affect women's lives post-treatment but also on how these issues can be resolved to
improve diagnosis and treatment of the disease."
Reviewer's comment: The statement emphasizes the need for a holistic approach that considers
both post-treatment challenges and proactive measures to improve diagnosis and treatment. To
strengthen the discussion, consider suggesting specific strategies or policy recommendations
that address these issues comprehensively.
"We recommend that sociocultural factors influencing breast cancer diagnosis and treatment be
incorporated into breast cancer awareness programs, education, and intervention programs in
Ghana."
Reviewer's comment: The recommendation to incorporate sociocultural factors into breast
cancer awareness and intervention programs is relevant and significant. Consider expanding on
the potential benefits of integrating cultural sensitivity into these programs and how it could lead
to better outcomes for women with breast cancer.
"We believe these will help inform women and encourage them to report to health facilities early
with breast cancer symptoms to initiate timely diagnosis and treatment to improve the outcomes
of the disease in Ghana."
Reviewer's comment: The belief in the potential positive impact of these interventions is well-
stated. To reinforce this point, consider citing evidence from similar successful interventions in
other settings that have led to improved early diagnosis and treatment outcomes.
"Further research is required to explore appropriate multidimensional culturally sensitive
intervention research that combines cultural beliefs and the treatment of breast cancer."
Reviewer's comment: The call for further research on culturally sensitive interventions is
essential. It would be helpful to suggest specific areas or aspects of research that need to be
explored, such as evaluating the effectiveness of culturally tailored interventions in different
Ghanaian communities.
"Conclusion
This study adduces evidence on the sociocultural beliefs that impact on untimely diagnosis
and treatment of breast cancer among women in Ghana. As policymakers, clinicians, and other
stakeholders strive to improve breast cancer diagnosis and treatment, there is a need to focus on
the role of sociocultural beliefs within Ghanaian communities."
Reviewer's comment: The conclusion effectively summarizes the key findings and implications
of the study. Consider adding a sentence that emphasizes the urgency of addressing sociocultural
beliefs to improve breast cancer outcomes in Ghana and potentially reduce breast cancer-related
mortality
Strengths and limitations of the study
GENERAL COMMENT:
In the "Implication for policy and practice" section, it would be beneficial to highlight the
strengths of the current scoping review. For instance, discuss the comprehensive search strategy
adopted following the JBI guidelines and PRISMA-ScR reporting, which ensured a thorough
and systematic identification of relevant literature. Additionally, mention the inclusion of both
qualitative and quantitative studies, which allowed for a more comprehensive understanding of
the sociocultural beliefs influencing breast cancer diagnosis and treatment in Ghana.
Regarding the limitations, it is essential to address potential sources of bias or methodological
constraints that may have influenced the results. One limitation could be the language bias, as
the search was conducted in English-language databases, potentially excluding relevant studies
published in other languages. Additionally, discuss the potential for publication bias, as scoping
reviews may be more likely to include published studies, possibly overlooking unpublished or
gray literature that could contribute to a more comprehensive understanding of the topic.
In the "Conclusion" section, consider acknowledging the strength of the study's contribution
to the existing literature on the sociocultural beliefs impacting breast cancer diagnosis and
treatment in Ghana. Emphasize that the scoping review offers valuable insights into a previously
underexplored area and lays the foundation for further research and targeted interventions.
Including both strengths and limitations in the discussion will demonstrate a balanced evaluation
of the study's findings and provide a clearer understanding of the potential implications for policy
and practice based on the current evidence
Dr. Easter C. Osuchukwu
University of Calabar
Nigeria