Practice of opportunistic breast cancer screening and health education among healthcare workers in public health facilities in Ogun state, Southwest Nigeria: a qualitative study of barriers and facilitators

Abstract

Background

Globally, breast cancer is the most common cancer among women. Nigeria has the highest age-standardized breast cancer mortality rates in Africa, at 25.5 per 100,000. In the absence of organised breast cancer screening, opportunistic screening and health education during maternal health visits provide a crucial avenue for early detection and awareness. This study assessed the practices, barriers and facilitators of opportunistic breast cancer screening and health education among health workers in public health facilities in Ogun State, Nigeria.

Methods

This qualitative study utilized in-depth interviews (IDIs) with 43 healthcare providers (doctors, nurses, and community health extension workers) across primary, secondary, and tertiary health facilities.

Results

Across all levels of healthcare, health education on breast cancer is sometimes done during group health education sessions at antenatal clinics, postnatal clinics, infant immunization clinics and family planning clinics. In some health facilities, breast cancer health education is rarely done except when women complain of breast symptoms. Health education on breast cancer prevention focuses more on breastfeeding to prevent breast cancer, and self breast examination. No health worker mentioned advising women on yearly clinical breast examinations (CBE). Some health workers routinely perform CBE during antenatal visits, postnatal visits and family planning visits; some only do so when women have breast symptoms and others rarely do. The major facilitator to breast cancer screening and health education was health workers passion that women should not suffer from preventable cancers. Barriers to breast cancer screening and health education include manpower shortages, lack of facilities for screening in secondary facilities, geographic barriers, women’s ignorance, cultural/religious beliefs.

Conclusion

Integrating opportunistic breast cancer screening and health education into routine maternal health services can bridge critical gaps in early detection. Strengthening health system infrastructure, workforce capacity, and public awareness is essential to improving breast cancer screening uptake in Nigeria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13418-w.

Introduction

Globally, breast cancer is the most commonly diagnosed malignancy among women [1]. In 2022 alone, there were an estimated 2.3 million new cases of breast cancer and approximately 670,000 deaths attributed to the disease worldwide [2]. Among women, breast cancer accounts for more disability-adjusted life years (DALYs) lost than any other cancer, underscoring its immense public health impact [2].

In high-income countries, improvements in early detection through organized screening programmes and advancements in treatment modalities have led to significantly improved survival rates for women diagnosed with breast cancer. In contrast, low- and middle-income countries (LMICs) continue to experience higher mortality rates, largely due to late-stage presentation, limited diagnostic capabilities, insufficient health infrastructure, and lack of access to affordable and effective treatment [3, 4]. Africa has the highest age-standardized breast cancer mortality rate globally, with sub-Saharan Africa recording some of the highest incidence rates on the continent [3].

Nigeria ranks second in Africa in terms of breast cancer incidence, following after Mauritius [5]. The age-standardized incidence rate of breast cancer in Nigeria was 50.5 per 100,000 women in 2012 and is projected to increase to 84.2 per 100,000 by 2030 [5]. Nigeria has the highest age-standardized breast cancer mortality rate on the continent, at 25.9 per 100,000 [5]. A major contributor to this high mortality is the late stage at which patients present, with over 70% of Nigerian women diagnosed at Stage III or IV [5]. This trend reflects a broader pattern of delayed care-seeking behaviour, poor awareness, and limited access to diagnostic and treatment services [6, 7].

Early diagnosis of breast cancer, and appropriate treatment is linked with a decrease in both morbidity and mortality from the illness [8]. Approaches to the screening of breast cancer include self-breast examination (SBE), clinical breast examination (CBE), mammography and breast ultrasound amongst others [8]. Screening programmes must ensure the diagnosis of breast cancer at the earliest possible stage when treatment is most effective, and cure is most likely [8] Screening approaches vary between countries. In some countries, there are organized screening programmes that systematically tests all women in the defined target group [9, 10]. Opportunistic screenings, unlike organized screening, is when women get screened because of recommendation made by a healthcare provider or of the woman’s choice. This is usually the case in low- and middle- income countries [9] In Nigeria, there are no organized breast cancer screening programs and breast cancer screening is mostly opportunistic [11]. Occasionally however, government agencies, civil society or religious organisations organise breast cancer screening outreaches in communities.

Nigeria has a large population of women of reproductive age, of about 40 million women [12], and with the country’s high total fertility rate of 5.3 children per woman [13] and fairly high antenatal care coverage rate of 67% [13], maternal health visits could serve as a window of opportunity for women to receive health education on breast cancer prevention and get screened for breast cancer [13]. This is a form of opportunistic screening. Women can receive clinical breast examination (CBE) at antenatal and postnatal visits and be linked with other breast cancer screening services like imaging when needed. This qualitative study assessed the practices of health practitioners in public health facilities in Ogun State, Nigeria as regards opportunistic breast cancer health education and screening. Findings will help strengthen breast cancer prevention efforts in the country.

Methods

Study setting

Ogun State is located in Southwest Nigeria and has a 2021 projected population of 6,379,500 [14]. The state has 20 Local Government Areas (LGAs) with a mix of urban and rural communities. There are three public tertiary hospitals – two of which are multi-specialist hospitals and the third, a neuropsychiatric hospital. The State has 29 public secondary hospitals and 500 primary health centers (PHCs). There were 895 registered and functional private health facilities in the State as of June 2024.

Study design and population

This study on breast cancer opportunistic screening was part of a qualitative research project that aimed to assess the practice, facilitators and barriers of health workers towards breast and cervical cancer opportunistic screening in Ogun State, Nigeria. This research is a qualitative study that utilised in-depth interviews (IDIs). The study population includes doctors, nurses and Community Health Extension Workers (CHEWS), that were working in antenatal and postnatal clinics in public primary, secondary and tertiary health facilities in Ogun State. Eligible participants were healthcare workers with at least a year of working experience at any of the selected health facilities in the state.

Sampling methodology

Health workers were recruited from public primary, secondary, and tertiary healthcare facilities offering maternal health services, including antenatal care, delivery, and postnatal services in Ogun State, Nigeria. A quota sampling technique was employed to select health facilities across the state’s three senatorial districts: Ogun Central, Ogun East, and Ogun West. The number of facilities selected from each district was proportionate to the distribution of public health facilities across senatorial districts. To ensure representativeness, facilities were purposively chosen to include both urban and rural local government areas (LGAs) within each district. Eleven health facilities were selected from Ogun Central, 10 from Ogun East, and 6 from Ogun West senatorial zones.

Within each selected facility, healthcare providers were purposively recruited based on the following inclusion criteria: (1) having a minimum of one year of employment at the facility, and (2) regular interaction with pregnant and postpartum women during antenatal or postnatal care, either through clinical consultations or participation in group health education sessions. From each secondary and tertiary facility, one doctor and one nurse were selected. From each primary health centre, one nurse or community health extension worker (CHEW) was recruited.

Data collection

Data was collected from December 3rd 2023 to January 15th 2024. A total of 43 health workers participated in in-depth interviews (IDIs) using a semi-structured interview guide comprising open-ended questions. Participants were contacted in advance, and interviews were scheduled at a mutually convenient time and location. To facilitate data collection, six resident doctors from the Department of Public Health at one of the state’s tertiary hospitals, who had prior experience in qualitative data collection, were trained in qualitative research methods and served as research assistants for the study.

The research assistants conducted the interviews using the interview guide which contained open ended questions on participants’ knowledge of breast cancer, their practices related to breast cancer health education, the availability of breast cancer screening services within their facilities, barriers and facilitators to screening, their engagement in opportunistic breast cancer screening, and recommendations for improving breast cancer education and screening practices (see Additional file 1). Probes and follow-up prompts were used to elicit detailed and nuanced responses.

In addition to audio recording, the research assistants took observational notes to document non-verbal cues and contextual factors that might enrich the data. Each interview lasted approximately 60 min on average.

Data analysis

All interview recordings were transcribed verbatim, and transcripts were subsequently reviewed for accuracy and completeness. Data analysis was conducted using NVivo version 13 (QSR International), a qualitative data management software. A hybrid thematic analysis approach was employed, combining both deductive and inductive methods. Initially, a deductive coding framework was applied, based on a priori themes derived from the interview topic guide. Relevant sections of the transcripts were mapped to these predefined themes, and subthemes were developed as needed to capture the diversity of participants’ responses. In addition, an inductive approach was used to identify emerging themes from the data that did not align with the initial coding structure. These newly identified codes and themes were developed iteratively through close reading of the transcripts, allowing for a more comprehensive understanding of the data and capturing perspectives not anticipated in the topic guide.

Research quality and rigor

To ensure methodological rigor, the study was guided by Lincoln and Guba’s framework of trustworthiness, encompassing credibility, confirmability, dependability, and transferability [15].

Credibility

was established through several strategies. Probes and follow-up prompts were consistently employed during interviews to elicit in-depth responses and ensure that participants’ perspectives were fully explored. Member checking was conducted by sharing summaries of the findings with a subset of participants, who confirmed that the interpretations accurately reflected their experiences and views.

Confirmability

was strengthened by ensuring that the findings were grounded in participants’ narratives rather than researcher bias. Three members of the research team independently coded a sample of transcripts, and any discrepancies were resolved through discussion to reach consensus.

Dependability

was ensured through a transparent and systematic research process. Detailed documentation of the research design, interview procedures, transcription, and analytic steps were maintained to allow for replication. Consistency in data interpretation was supported by a code-recode procedure, where selected transcripts were recoded at different times to assess stability of coding. Peer debriefing sessions with colleagues not directly involved in the data collection further enhanced the consistency and reliability of the findings.

Transferability

has been addressed by providing descriptions of the study setting, including the structure of the public health system in Ogun State, the practice of breast cancer screening in Nigeria, and the professional background of participants in the introduction and study setting sections of this paper. We have used rich, illustrative quotations from respondents to allow readers to appraise the relevance of the findings to other contexts. These detailed contextual descriptions enhance the applicability of the study insights to similar low-resource settings within Nigeria and beyond.

Through the integration of the above strategies, this study upheld the rigor and trustworthiness expected in qualitative research, thereby strengthening the validity and credibility of our findings.

Results

Background characteristics of participants

The mean age of participants was 43.4 ± 1.4 years and most participants 29 (67.4%) were female. Five (11.6%) participants were practicing in tertiary health facilities, 24 (55.8%) in secondary health facilities and 14 (32.5%) in primary health centers. Three (7%) were CHEWS, 25 (58.1%) were nurses, and 15 (34.9%) were doctors. The majority, 29 (67.4%) were senior cadre health workers, 21 (48.9%) had over than 20 years’ work experience; and most, 29 (67.4%) had been in their current place of assignment for 2-5years (Table 1).

Table 1.

Background characteristics of participants

Variable	Frequency (n = 43)	Percentage
Age (years)
20–29	2	4.7
30–39	10	23.3
40–49	20	46.5
50–59	11	25.6
Mean ± SD	43.4 ± 1.4
Sex
Female	29	67.4
Male	14	32.6
Level of health facility
Primary	14	32.6
Secondary	24	55.8
Tertiary	5	11.6
Occupation
CHEW	3	7
Nurse	25	58.1
Doctor	15	34.9
Cadre
Junior cadre	8	18.6
Middle cadre	6	14
Senior cadre	29	67.4
Years of experience
2–9 years	13	30.2
10–20 years	21	48.9
≥ 20 years	9	20.9
Years on job
2–5 years	29	67.4
6–10 years	6	14
> 10 years	8	18.6
Senatorial district of practice
Ogun Central	18	41.9
Ogun East	16	37.2
Ogun West	9	20.9
Place of practice
Urban LGA	22	51.2
Rural LGA	21	48.8

The themes and sub-themes from data analysis are shown in Table 2.

Table 2.

Themes and sub-themes from data analysis

s	Themes	Sub-themes
1	Knowledge of breast cancer screening
2	Breast cancer health education	• Practice of breast cancer prevention health education • Barriers to breast cancer health education • Facilitators of breast cancer health education
3	Breast cancer screening	• Access to facilities for breast cancer screening • Practice of breast cancer screening • Barriers to breast cancer screening faced by health workers • Barriers to breast cancer screening faced by patients • Facilitators of breast cancer screening
4	Recommendations for opportunistic breast cancer screening and health education

Knowledge of breast cancer screening

All the health workers knew about breast cancer screening. It was said that breast cancer screening was done to detect abnormality in the breast or signs of breast cancer early, so there can be early interventions to prevent complications. Health workers commonly described breast cancer screening as breast examination for lumps which can be excised and biopsied. More doctors than nurses mentioned breast ultrasound (USS) and mammography as methods of breast cancer screening. Breast imaging was also more commonly mentioned by health workers from tertiary and secondary health facilities, compared with primary facilities.

“Well, to the best of my knowledge, breast cancer screening is just like a kind of examination that is usually done for women, to check abnormalities in their breasts so that there can be early interventions and treatments, and to prevent complications, and probably mortality”. [Secondary hospital nurse; Female;10 years of work experience]

“What I know about breast cancer screening? When you come to the hospital, they will examine your breast. Then if there’s no lump, no problem, but if there’s any lump, they will ask you to remove it. After the removal, you send the sample to the lab. If there’s any anything there… like if the sample is cancerous, that means they are going to remove the breast. But if there’s nothing, you are free”. [Secondary hospital nurse; Female; 17 years of work experience]

“Well, basically it entails breast ultrasound, mammography and ehm self-breast examination”. [Secondary hospital doctor; Male; 8 years of work experience]

Breast cancer health education

Practice of breast cancer prevention health education

In many health facilities, primary, secondary and tertiary alike, health education on breast cancer prevention takes place during group health education at antenatal, postnatal and infant immunization clinics. In some health facilities, breast cancer health education is done alongside CBE, routinely, during family planning visits. A PHC nurse said this practice is done to identify breast lumps that may have preceded the use of the contraceptive method. Breast cancer health education is usually done by nurses during group education and most doctors only counsel patients on breast cancer prevention when they have patients that present with breast symptoms.

“In my facility, we do health educate patients on breast cancer, and it’s mostly done during antenatal clinic which comes up on Tuesdays, then the post-natal and whenever any patient comes for family planning too, they are being educated about, breast cancer screening”. [Secondary hospital nurse; Female; 20 years of work experience]

“Most discussions regarding breast cancer are usually during the antenatal period, because the antenatal affords us the largest gathering, the largest number of women are gathered during antenatal clinic visit. So, most times it’s the nurses that gather them and tell them so many things regarding the antenatal processes, but breast cancer and breast screening is still part of what they talk about because it’s part of reproductive health”. [Tertiary hospital doctor; Male; 16 years of work experience]

“When they come for family planning as a client, it’s part of the counselling we give them and when they choose any of the methods… we also do breast examination. It’s part of the breast examination”. [PHC nurse; Male; 19 years of work experience]

“So, we counsel our women, during family planning or outreach. We tell them they should try to examine their breasts, because when some of them have lumps, if they are on family planning, they will say, it’s that family planning that caused it? Whereas the lump is already there before the family planning”. [PHC nurse; Female; 18 years of work experience]

“Well, it’s not what we do here, but occasionally, especially for a patient that has, you know, maybe history of breast pain, family history of breast cancer, we advise and refer appropriately. We are not centred on that. So, we don’t dwell on that and it’s not something we do routinely”. [Secondary hospital doctor; Male; 8 years of work experience]

For many health facilities, there were health education discussions with women on the importance of breastfeeding for optimal child nutrition, the importance of breastfeeding as a form of family planning, and also as a form of prevention for breast cancer. There were also discussions with women on the importance of SBE in preparing for breastfeeding and also to detect breast lumps. Women were told to look out for skin changes over their breast and examine their breasts for nipple inversion and lumps. Health workers tell women to report to the hospital if they notice any abnormalities with their breast during SBE.

Although many health workers mentioned that they discuss SBE with women during health education, many did not mention that other screening methods were discussed. Some, however, mentioned that they recommend mammography and USS to patients with breast lumps, and these were mostly doctors in tertiary and secondary health facilities. None of the health workers interviewed mentioned they advise women to visit the hospital yearly for CBE.

“As they will be breastfeeding the baby regularly, it will prevent the breast cancer. But, mixing artificial milk plus breast milk or loading the breast milk in the breast, without giving the baby can cause breast cancer”. [Secondary hospital nurse; Female; 5 years of work experience]

“We just educate them about physical examination of the breast. Let them know that they should examine their breast. So that if there are any changes or any signs, they should visit the clinic and report”. [Secondary hospital nurse; Female; 13 years of work experience]

“We tell them if they observe any growth or any lump on their breasts, whether painful, or not painful, that they should report to the hospital, and if there is any abnormal appearance on the nipples, if there’s any developments, maybe pain, or any discharge from the nipple, they should come to the hospital…” [Secondary hospital nurse; Female].

“Yes of course, we let them know the importance of breast ultrasound… the importance of mammography. Yes, the importance of course, of doing the routine self-breast examination”. [Secondary hospital doctor; Male; 14 years of work experience]

Some health workers, all of which were nurses, demonstrated limited knowledge of breast cancer screening, by wrongly educating women, that in order not to have breast cancer, they should avoid wearing tight bras and putting money in their bras.

“Then, at times, some of them used to put money in their breast, under their bra. To keep their money. They should stop the habit of doing that”. [Secondary hospital nurse; Female; 19 years of work experience]

“Then we also tell them the use of bras and brazier. They should be putting on not too firm bras”. [Secondary hospital nurse; Female; 18 years of work experience]

In some health facilities, health education on breast cancer prevention is rarely done. In some secondary health facilities, health workers in the obstetrics department feel breast cancer screening and health education is in the purview of the general surgeons and so don’t practice or ‘preach’ it.

“Hardly, hardly. It doesn’t usually come up, hardly” spoken with a dismissive wave of the hand [Secondary hospital doctor; Male;19 years of work experience].

“Not at all, ma” shaking her head firmly, as though the matter required no further explanation [Secondary hospital nurse; Female; 14 years of work experience].

“Well, not really….Except they have complained” the nurse admitted after a long pause, her voice dropping, as though reluctant to acknowledge the gap in routine practice. [PHC nurse; Female; 4 years of work experience]

“ehm to be candid, we don’t routinely discuss about breast…” the doctor said hesitantly, fidgeting with his pen, indicating some discomfort in addressing the topic. [Tertiary hospital doctor; Male; 10 years of work experience]

“During our postnatal,.I don’t think we discuss around breast cancer prevention. Since the department does not really take care of anything breasts…we refer them to surgical department.” [Secondary hospital doctor; Male; 8 years of work experience].

Barriers to breast cancer health education

Some health workers said they have no challenges in giving health education. Some mentioned heavy workloads, manpower shortage and not having enough time for health education. A male doctor mentioned that gender disparity could be a barrier to health education as women often feel freer with female health workers. Religious beliefs, women not interested in health talks, and being in a hurry to go back to their workplaces, were also mentioned as barriers. A few health workers said they experience language barrier when providing health education.

“No, there’s none. I’m the one that will talk. So, their own is just to listen”. [Secondary hospital doctor; Female; 17 years of work experience]

“In this environment, gender differences are there. Right? The females feel freer with their female counterparts. They open up more to the female counterparts than you a male. Another problem that comes to mind is the aspect of religion, as well. You know, ehm… most of the religions, actually consider those aspects as scared”. [Secondary hospital doctor; Male; 14 years of work experience]

“It is still shortage of manpower, because for two nurses to be manning the ward and still come back to give health education, Then the time also…because for you to give quality health education, you need to have enough time for them…” [Secondary hospital nurse; Female; 18 years of work experience].

“Sometimes we have people that do not understand the lingua franca, English or Yoruba. So, you need a translator. In short, we have a whole lot of them, because this community is mixed, we have Fulanis, we have people from Cotonou, we have Igedes, we have a lot of people, so most of the things I might want to tell them gets lost in translation”. [Secondary hospital doctor; Male; 19 years of work experience]

“The truth is ehm, most people, most especially this facility when they come, they are interested in what they came for, not the health talks. Most of them are actually interested in why they are in the hospital”. [Secondary hospital doctor; Male; 14 years of work experience]

Facilitators of breast cancer health education

The major facilitator for breast cancer health education was health workers desire that no woman should die from preventable cancers. The routine practice of health education during antenatal clinics is also a facilitator to educating women on breast cancer. Some health workers mentioned that women who are more educated and enlightened are easier to educate on breast cancer screening as they can easily comprehend the discussions. When women demonstrate interest in health education, it also motivates health workers to provide health education.

“For me personally, I will say; because I’ve seen cases of survivors of breast cancer, that has really encouraged me. If this thing is preventable, then why can’t we prevent it? Why should anyone die because of breast cancer. So, I think that is a motivation for me”. [Secondary hospital nurse; Female; 10 years of work experience]

“Health education is a must. Breast and cervical cancer health education is compulsory. We counsel them any time especially on the ANC and infant welfare clinic. It is the normal thing we do every every time”. [PHC nurse; Female; 33 years of work experience]

… “Most time, the educational level or the status of the patient matters…. If you are explaining to a pepper seller that you have some cancer, they will not understand. They will not relate as well with you compared to somebody that is more enlightened, that is more exposed or has heard of things like that. Educational status makes your job easy, which means you do less talking”. [Secondary hospital doctor; Male; 17 years of work experience]

“In all sincerity, the motivation comes from the clients. When you have a client who you are sure is interested, then you really want to help the client. But when the patient is interested in something else, then only when you’re not overburden, that the interest comes. But when you have so much to do, you get discouraged”. [Secondary hospital doctor; Male; 13 years of work experience]

“If the patient is ready to listen to me and take my advice, I am ready to give the patient my own knowledge - the patients that are willing to listen and are ready to carry out the examination”. [PHC CHEW; Female; 4 years of work experience]

Breast cancer screening

Access to facilities for breast cancer screening

CBE is readily accessible to women as it can easily be done, without any equipment. Breast USS and mammography are available in both tertiary institutions. However, for most secondary hospitals and the PHCs, facilities for mammography are not available and women have to be referred to tertiary facilities, which many times are far away. Some secondary hospitals have facilities for breast ultrasound.

“If you are talking about breast self-examination or breast examination for women, then we do it for them. We have where we do it. We do palpation on our couch… And there is a private place for palpation of our patients, so we do it there. When we are talking about mammogram or whatever, we don’t do it here”. [PHC nurse; Female; 17 years of work experience]

“Well, unfortunately, where I work, is a bit far from Abeokuta. It’s about two hours, even though it is the same Ogun state, and the roads are not good, so it poses a challenge for patients to want to come down to Abeokuta, especially those whose cases or symptoms are not really full blown”. [Secondary hospital doctor; Male; 14 years of work experience]

“Yes, yes, it is. Ehm usually for women of reproductive age group with breast disease, either lumps or pain, the first modality of investigation is USS, which is accessible. We have 2D, we have 3D, and we have experienced ultra sonographers. So, we have the facilities. Its well accessible and available”. [Tertiary hospital doctor; Male; 10 years of experience]

Practice of breast cancer screening

Across all levels of health care, some health workers mentioned that they examine the breasts of women accessing maternal healthcare services in their facilities, while others said they do not. Among those that practice CBE, some did so as a routine practice during antenatal clinics, post-natal clinics, and family planning clinics while others do so when prompted by patient’s complaints. When a lump is detected during breast examination, it is often excised and sent for histology. Many doctors, and a few nurses mentioned that they usually send patients with signs and symptoms of breast disease for imaging – mammogram or USS. No health worker mentioned that they recommended breast mammogram or USS routinely to asymptomatic women as a form of screening for breast cancer. A doctor practicing in a secondary facility said they conduct breast USS for symptomatic women, as imaging test, as they don’t have mammography services in their facility.

“Then also antenatally too … we frequently check the breast of women. Check for whether they have inverted nipples, whether they have flat nipples. All those are ways where breast lump will be picked, and some women will volunteer their concerns about their breast. So, from time to time, we offer breast cancer information and screening information and the likes”. [Tertiary hospital doctor; Male; 10 years of work experience]

“…every patient cannot just come to me and complaining about what is not link to the breast… then I will bring in breast examination into that…. Unless a patient lay complain about the breast, then we can now talk about breast examination” [Secondary hospital nurse; Female; 16 years of work experience].

“We don’t usually do screening here” the participant stated flatly, with a shrug of the shoulders and a faint smile, as though it was an accepted norm within the facility. [PHC nurse; Female; 33 years of working experience]

“We were taught of breast examination in school, and we have been doing it. And sometimes we send them for mammogram, most times if we find a lump. Normally we remove the lump, and send for histopathology, and if it is cancerous, we normally refer them”. [Secondary hospital nurse; Female; 31 years of work experience]

“So, we do more of examination and ultrasound because we don’t have access to mammography. And based on ehnn our clinical suspicion of at least some… some patients, we send patients for hormonal (en) screening. We don’t do it routinely anyway, but once we have suspicions, and we send for other imaging studies to rule it out”. [Secondary hospital doctor; Male; 17 years of work experience]

Barriers to breast cancer screening faced by health workers

Several participants identified manpower shortages as a key barrier to providing breast cancer screening services, noting that they were already overburdened with clinical responsibilities. Health workers in secondary healthcare facilities reported a lack of essential screening infrastructure, including ultrasound scanners (USS), mammography units, and histopathology services, which limited their capacity to offer comprehensive screening and diagnostic follow-up.

Participants from primary and secondary facilities also highlighted geographic barriers, stating that women often needed to travel long distances to access imaging services for breast cancer screening. A few respondents working in multi-ethnic communities cited language barriers as a challenge to effective communication during screening and health education. Additionally, some health workers noted that reluctance among women to undergo breast examination was occasionally encountered, although one female provider remarked that she had never experienced patient refusal when performing clinical breast examinations (CBE). Conversely, many health workers reported no significant barriers to conducting CBEs in their facilities.

“There is none… I don’t think we have any barriers for that… If they want to have their screening done, we can do it for them anytime. Because it has to do with palpation”. [PHC nurse; Female; 20 years of work experience]

“We don’t have enough manpower. We are understaffed” [Secondary hospital nurse; Female; 31 years of work experience].

“Erm, it’s because we don’t have the facility and we don’t have the equipment on ground, so we still need to refer them. Then when we refer them, some will come back. In fact, the majority will not come back. Only a few will come back”. [Secondary hospital doctor; Male; 15 years of work experience]

“Well, aside for the radiological investigations that are not available, then maybe also histological tests, because it is not done here. Those are the barriers I’ve identified. Taking history and examination has no barrier at all, no barrier”. [Secondary hospital doctor; Male; 13 years of work experience]

“I never experienced any refusal because we are all women. So, I will first of all tell them what I am about to do. And they will give their consent”. [Secondary hospital nurse; Female; 16 years of work experience]

“Some patients will be telling you - nothing happen to me, don’t touch my breasts. So, you know, as a health. worker, we don’t to be need rough handled. We know that they don’t understand this thing… So, they’ll just talk to you anyhow….” [PHC CHEW; Female; 7 years of work experience].

Barriers to breast cancer screening faced by patients

Health workers identified the following barriers patients face regarding breast cancer screening: ignorance/poor knowledge on breast cancer, low level of education, long distance to referral centers, unaffordability of screening tests and transportation costs, superstitious and religious beliefs, fear of bad diagnosis, feeling of embarrassment, lack of interest in breast cancer screening, and use of alternative medicine. A health worker in a tertiary facility also stated that navigating complex hospital logistics is a hindering factor for women trying to get screened.

“Then, most of the time, it is lack of knowledge. Because they don’t really know the significance. Some of them who have this thing (breast cancer), and they think it is harmless. They would have scarified the lump and all that…” [Secondary hospital doctor; Male; 19 years of work experience].

“So, let’s say distance. The distance from where they are, to where they’re going to assess the test.…Most time it’s distance, because of the distance from where they are”. [Secondary hospital doctor; Female; 8 years of work experience]

“Superstition beliefs. They often say it’s a spiritual attack, a spiritual arrow, targeted at them from village people or somebody that wants to kill them and all that. And then you now see patients that should have just a simple lumpectomy, will go and will apply local medications to the breasts. Eventually these medications will now get them to have ulcer,… infection. And then from there, something that would have been so easy to treat, would become a very difficult case that ends up in mastectomy”. [Secondary hospital doctor; Male; 14 years of work experience]

“Hmm, I can say cultural believes is number one. The herbalists are not helping matters at all. I also think government has a lot of role to play. Because right now, government has licensed many herbalists. Just as we are telling patients one thing here, they are telling the patients the opposite in their own consulting room as well. I see no reason why government should license a person that sees a case of breast cancer and says it is a spiritual attack…” [Secondary hospital doctor; Male; 16 years of work experience].

“Transportation and financial aspects. When you make a referral, they’ll say there’s no money. They’ll say - We don’t have car to go. We know that we want to go. They’ve given us a referral letter, but there’s no transportation. So they cannot make use of the referral”. [Secondary hospital nurse; Female; 14 years of work experience]

“Some can just feel ashamed and say – Why can I just go and ask for a thing like that? I think what the barrier they may be facing is that – Can I open my breast for people to see?”

 [Secondary hospital nurse; Female; 16 years of work experience]

“One barrier too is fear. They might feel like they don’t want to know. Because some people believe that what they don’t know won’t kill them… (laughter). So, they don’t want to know at all if they have the disease.” [PHC nurse; Female; 2 years of work experience].

“My hospital could be quite frustrating at times because there are different points you have to go, and payment points you have to go to. And they are not close to each other. You have to pay somewhere; you have to go somewhere else for test. Patients get discouraged. They get tired along the line. So that could also be a factor”. [Tertiary hospital doctor; Male; 12 years of working experience]

Facilitators of breast cancer screening

Passion as a health worker and desire to prevent breast cancer was mentioned as a facilitator for screening. In some cases, screening was prompted by patient’s inquiry about the disease, and patient’s complaint of signs and symptoms of breast disease.

“It is because of the passion. I have a strong passion for what I do. I have seen people dying of breast and cervical cancer that ordinarily should not have died”. [Secondary hospital nurse; Female; 31 years of working experience]

“Enhh, … because most of the cases I have seen are late presentation. Late stage, almost stage four. So that prompts us to do so”. [Secondary hospital doctor; Male; 16 years of work experience]

“Like I said, most times, when the presenting complaint is related, be it pain or mass, so that encourages not only health education, but also the screening itself”. [Secondary hospital doctor; Male; 13 years of work experience]

Recommendations for opportunistic breast cancer screening and health education

Almost all the health workers said that there should be increase in the awareness of breast cancer prevention. It was said that awareness could be raised using IEC materials, with the use of the media, and via outreaches. More personnel, training and re-training of health workers, availability of required materials and equipment were also recommended by the health workers. Many health workers mentioned that breast cancer health education should be routine at antenatal clinics, and some mentioned that breast cancer screening should be incorporated into the routine ANC. Some health workers said that breast cancer screening should be made free by the government. One doctor suggested that if incentives are given to women, it will encourage them to get screened.

“We should get the IEC materials. We get them and display so that we are serious about it. All the nurses working in the ANC and PNC should be trained on cervical and breast cancer screening”. [Secondary hospital nurse; Female; 31 years of work experience]

“At the government level, they should employ more health workers. So as to allow us to do our job right - to avoid heavy workload on the nurses on duty. So, they should please, employ more working hands… ” [Secondary hospital nurse; Female; 18 years of work experience].

Another thing that is peculiar to my environment here is that they should make the road motorable”. [Secondary hospital doctor; Male; 8 years of work experience]

“Maybe government should facilitate this education and training for health workers and provide all the improvements and all the necessary equipment that we supposed to be using for this screening”. [PHC nurse; Female; 22 years of work experience]

“Yes. What I feel is that at every antenatal clinic, all women, all pregnant women should be screened. All women should be screened during antenatal clinic. And even during their postnatal clinics too, nursing mothers that bring their children for immunization should also be screened”. [PHC nurse; Female; 17 years of work experience]

“What can be done is through this health information we are giving. But at the same time, as we are giving this information, they should provide free screening. People like free things. Most of them find it difficult to pay for their ANC test. But by the time they now put in place free screening test, you will see many people will be available to do this test”. [Tertiary hospital nurse; Female; 32 years of work experience]

Discussion

This study was carried out to investigate the practice of opportunistic breast cancer screening and health education among health workers providing maternal health services at sub-national level to show case facilitators and barriers towards this preventive service delivery. All the health workers knew about breast cancer screening and could mention some of the screening methods. There were however some gaps in breast cancer risk factor knowledge and only few nurses mentioned breast imaging as one of the breast cancer screening modalities. When breast cancer health education was done, it was mostly done during group health education sessions by nurses and doctors mostly educate when patients have symptoms. Practice of opportunistic screening varied among health workers. CBE was the most common screening method practiced. A few health workers recommended breast imaging for women with breast symptoms. None of the health workers recommended/educated women on the need for yearly CBE.

All the health workers knew about breast cancer screening with almost all mentioning SBE and CBE as methods of breast cancer screening. Many doctors and a few nurses also mentioned breast USS and mammography as methods of screening. There was however some knowledge gap with some health workers educating women that wearing tight bras and putting money in bras are risk factors for breast cancer. Similar to our study, in a study among female health workers in Benin City, Southern Nigeria, awareness of breast cancer screening methods was high. However, unlike our study where only few nurses and one CHEW made mention of mammography, awareness of mammography in the Benin study was high [16]. The Benin study was carried out in two large hospitals – one tertiary and one secondary. In our study however, many of our respondents included PHC staff and mention of breast imaging was only made by two PHC nurses. In addition, many health workers in our study don’t routinely recommend breast USS or mammography to women, hence it does not come readily to mind.

The wrong belief that breast cancer is caused by wearing tight bras and putting money in bras is common in Nigeria [17–19]. A study among undergraduates revealed this was a common misconception by students [18]. This misconception was also found in a study among rural dwellers in Nigeria [19]. Some health workers in our study also shared this belief. It is imperative to correct such wrong misconceptions among health workers, so women get the right messages and take correct actions, rather than incorrect actions to prevent breast cancer.

Even though breast cancer health education was done during group health education at antenatal, postnatal/infant immunization clinics and sometimes during visits for family planning in many health facilities, it was rarely or not done in other health facilities. The finding of group health education is not surprising as it is a usual practice in public hospitals in Nigeria and other African countries, for women to undergo group health education with nurses, before doctor’s consultation begins [20–22]. This practice provides an avenue for women to be educated on various topics including the woman’s nutrition during pregnancy, child breastfeeding, danger signs in pregnancy, and birth preparedness amongst others. It is a good practice that many health workers in our study also use this opportunity to provide education on breast cancer screening, even though discussions focus mostly on breast feeding as a form of breast cancer prevention and only sometimes do the discussions include the use of SBE as a form of breast cancer prevention measure. Health workers who do not practice breast cancer health education should be encouraged to educate women on breast cancer screening using the opportunities available to them. Doctors should play more active roles in educating and counselling women on screening, even when the women have no symptoms, and health workers should also educate women on the need for yearly CBE.

Regarding the practice of breast cancer screening, Some health workers reported that they practice CBE routinely during antenatal visits, postnatal visits, and at family planning clinics. Some health workers rarely practiced CBE, and some only do when women have breast symptoms. Another study conducted among antenatal attendees in a tertiary hospital in southeast Nigeria showed that only 3% of attendees had a CBE done at their current visit [23]. Apart from examining the breast during antenatal clinics to look for possible signs of breastfeeding problems, examination of the breasts is also useful for early detection of breast cancer. It is advisable that health practitioners use the opportunity ANC presents to screen women for breast cancer.

Our study also revealed that Some doctors refer only women with breast symptoms for USS or mammography, but there was no mention of routine recommendation of breast imaging for all eligible women. In another study in Nigeria, among female health workers, majority also never refer eligible women for mammography. Also, in a qualitative study among health workers in a rural area in Crete, only eight out of 28 health workers refer all eligible women for mammography [24] In Brazil however, most health workers request an annual mammogram [25] Referral of eligible women for mammography is a recommended practice, and this can be encouraged to be a regular practice among health workers. However, inadequate radiologist manpower, inadequate referral centers for breast imaging and high cost to women, may make this less impracticable.

Most health workers stated they had no challenges with giving health education, though some mentioned shortage of staff, heavy workload, poor training and language barrier. Barriers to breast cancer screening also include heavy workload and shortage of staff, inadequate facilities for screening in some facilities, and some patient’s refusal to be examined. Similar barriers have been reported in other studies [25, 26]. In a study among primary health care workers in rural South Africa, inadequate healthcare provider competency for the cancer screening, shortages in screening facilities, supplies, and human resources were identified barriers to screening [25, 26]. Adequate work force, training and adequate screening facilities are needed to improve breast cancer screening practice among health workers. Many health workers in our study however said they had no barriers to performing CBE as it did not require special equipment.

Patient-related barriers to breast cancer screening mentioned by the health workers in this study include women’s ignorance on breast cancer screening, poverty, low level of education, cultural and spiritual beliefs, fear of bad diagnosis, long distance to referral centers and feeling of embarrassment, especially with male health workers. The finding of cultural inhibitions to breast cancer screening, poor accessibility to health facilities and economic constraints was also reported in a study in rural South Africa [27] and also in rural India [28]. A study among women in Kenya like our study also showed poor knowledge as a barrier to screening [29]. A study conducted in six European countries also showed that distance to clinics was a problem in two countries and poor awareness of the objectives of screening and its relevance was a barrier especially among women from Ethnic minorities [30].

The most commonly reported facilitator to breast cancer screening and health education in our study was health workers desire that no woman should die from preventable cancers. Some health workers also mentioned that having educated patients or more enlightened patients make them more likely to provide breast cancer health education, as such women can easily comprehend and imbibe the breast cancer prevention messages. While it is commendable that many health workers are passionate that women should not die from preventable cancers, all health workers should be encouraged to provide health education and screening to all women irrespective of educational status or illiteracy. Health workers need to be trained on the appropriate communication skills and the patience and empathy required to educate less enlightened women.

Health workers made several recommendations to improve breast cancer screening and health education. which includes health system strengthening measures including adequate staffing, training of health workers, and provision of facilities and more centres for screening, amongst others. Interventions to increase breast cancer early detection should also include improving awareness of breast cancer screening among the populace and among women visiting health facilities. Education aids should be made available and displayed at health facilities to provide information to women on breast cancer prevention. Improving affordability of screening through cost-reduction/cost-free schemes or health insurance is also very crucial.

Strengths and limitations

To our knowledge, this is the first study conducted among health workers in Nigeria to assess their practice of opportunistic breast cancer screening and health education for women utilising maternal health services and thus, this study contributes significantly to the body of literature. This study, however, has some potential limitations. The study findings were from public health facilities and did not include private health facilities. Practice of opportunistic breast screening may differ in private facilities, which was not captured in this study, thus, this may limit the transferability of the findings to all healthcare settings in Ogun State and similar contexts. Another limitation is the possibility of health workers giving socially desirable responses (social desirability bias). This was however minimized by assuring the participants of confidentiality and making them know that the purpose of the research was to understand the current practice in order to make recommendations, and not to apportion blame. Nevertheless, this study presents significant findings that can contribute to policy and practice in reducing the burden of breast cancer in Nigeria.

Conclusion

In conclusion, practice of opportunistic breast cancer screening and health education varies among health workers, with some health workers educating women on SBE, performing CBE during maternal health visits and referring women for breast imaging when symptoms suggest, while others rarely educate women on breast cancer prevention nor practice screening for breast cancer. Health education also mostly focused on breastfeeding importance and SBE and rarely included recommendations for yearly CBE or breast imaging. Challenges to screening and health education includes health system factors, socio-economic factors and cultural factors. In order to increase breast cancer screening in Nigeria, training of healthcare professionals should emphasise and encourage the offering of opportunistic breast cancer screening and health education. Furthermore, these offerings should be included in the maternal health services, together with the relevant guidelines. Strengthening the health system, addressing socio-cultural barriers among women and enhancing financial accessibility are also essential, as these barriers to screening were identified by health workers in this study.

Authors’ contributions

TO conceptualized the study and wrote the study protocol. TS contributed to the study design. TO, KOI, SOO, collected the data for the study. TO conducted the data analysis with assistance from KOI and SOO. TO wrote the first draft of the manuscript. AO, FW, IOM, MB, TA, TS, OIA, EO, TPK and OIA critically reviewed the manuscript. All authors reviewed the manuscript and approved the final draft.

Funding

This study was funded by MSKCC-ARGO Global Cancer Disparities Pilot grant.

Data availability

The data used and/or analysed during the current study available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from Ogun State Health Research and Ethics Committee (OGHREC/467/161). Permission was obtained from the health facility managers. Written informed consent was collected from the participants, and confidentiality was maintained by conducting interviews in private rooms and using unique identifiers rather than names in the transcripts. Consent to record the IDIs was also obtained. All procedures were in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.