The Integrated Breast Cancer Educational Program in Indonesia: A Mixed-Methods Study Among Breast Cancer Patients and Survivors in Indonesia Breast Cancer Ed Indo
Abstract
Objective: This study aimed to develop an audience-tailored breast cancer educational program in Indonesia informed by factors associated with delayed breast cancer diagnosis.
Methods: This multiphase mixed-methods study followed a QUAL-QUAN-QUAL sequence. Eligible participants were patients and survivors aged ≥18 years with confirmed breast cancer and no cognitive or communication impairment; caregivers were included in phase 1. Phase 1 used purposive and snowball sampling with deductive matrix-based framework analysis. Phase 2 comprised an online cross-sectional survey and multivariable logistic regression. Phase 3 used multidisciplinary expert interviews to integrate the preceding findings into an educational program.
Results: Twenty-five interview participants and 379 survey respondents were included. Qualitative findings identified knowledge, breast-health behaviors, diagnostic pathways, and social influences as key domains related to delayed diagnosis. Higher knowledge (aOR, 0.87 per 10-point increase; 95% CI, 0.77–0.98) and personal financing (aOR, 0.61; 95% CI, 0.37–0.99) were associated with lower odds of delay, while not performing regular breast self-examination was associated with higher odds (aOR, 2.10; 95% CI, 1.01–4.35). Integrated findings informed an audience-specific educational program tailored for the general public, patients, caregivers, health workers, and health educators.
Conclusion: Delayed diagnosis in Indonesia was associated with knowledge gaps, breast-health behaviors, diagnostic factors, and social factors. These findings informed an audience-tailored educational module to address key barriers to timely diagnosis and to effectively reach the primary target audiences.
References
Frances FZ, Hull R, Khanyile R, Dlamini Z. Breast cancer in low-middle income countries: abnormality in splicing and lack of targeted treatment options. Am J Cancer Res. 2020;10(5):1568-91. doi: 10.7150/ajcr.45676
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-49. doi: 10.3322/caac.21660
da Costa Vieira RA, Biller G, Uemura G, Ruiz CA, Curado MP. Breast cancer screening in developing countries. Clinics. 2017;72(4):244-53. doi: 10.6061/clinics/2017(04)09
Sobri FB, Bachtiar A, Panigoro SS, Ayuningtyas D, Gustada H, Yuswar PW, et al. Factors Affecting Delayed Presentation and Diagnosis of Breast Cancer in Asian Developing Countries Women: A Systematic Review. Asian Pac J Cancer Prev. 2021;22(10):3081-92. doi: 10.31557/APJCP.2021.22.10.3081
Trochim WMK, Donnelly JP. Research methods knowledge base [Internet]. 2001 Aug 8. [cited 8 8 2026]. Available from: https://www.semanticscholar.org/paper/Research-methods-knowledge-base-Trochim-Donnelly/d8e92b6d6ea66fdfcf3546b33ab0ad5649aaf597
Shamsi U, Khan S, Azam I, Usman S, Maqbool A, Gill T, et al. Patient Delay in Breast Cancer Diagnosis in Two Hospitals in Karachi, Pakistan: Preventive and Life-Saving Measures Needed. JCO Glob Oncol. 2020;6:873-83. doi: 10.1200/GO.20.00034
Zhang H, Wang G, Zhang J, Lu Y, Jiang X. Patient delay and associated factors among Chinese women with breast cancer: a cross-sectional study. Medicine (Baltimore). 2019;98(40):e17454. doi: 10.1097/MD.0000000000017454
Mujar NMM, Dahlui M, Emran NA, Hadi IA, Wai YY, Arulanantham S, et al. Complementary and alternative medicine (CAM) use and delays in presentation and diagnosis of breast cancer patients in public hospitals in Malaysia. PLOS ONE. 2017;12(4):e0176394. doi: 10.1371/journal.pone.0176394
Taib NA, Yip CH, Low WY. Recognising symptoms of breast cancer as a reason for delayed presentation in Asian women--the psycho-socio-cultural model for breast symptom appraisal: opportunities for intervention. Asian Pac J Cancer Prev APJCP. 2011;12(6):1601-8.
Norsa’adah B, Rampal KG, Rahmah MA, Naing NN, Biswal BM. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer. 2011;11(1):141. doi: 10.1186/1471-2407-11-141
Dyanti GAR, Suariyani NLP. Faktor-faktor keterlambatan penderita kanker payudara dalam melakukan pemeriksaan awal ke pelayanan kesehatan. J Kesehat Masy. 2016;11(2):276-84. doi: 10.15294/kemas.v11i2.3742
Klimberg VS, Rivera A. Ultrasound image-guided core biopsy of the breast. Chin Clin Oncol. 2016;5(3):33. doi: 10.21037/cco.2016.04.05
Bevers TB, Helvie M, Bonaccio E, Calhoun KE, Daly MB, Farrar WB, et al. Breast Cancer Screening and Diagnosis, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2018;16(11):1362-89. doi: 10.6004/jnccn.2018.0083
Senkus E, Kyriakides S, Ohno S, Penault-Llorca F, Poortmans P, Rutgers E, et al. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 2015;26(suppl 5):v8-v30. doi: 10.1093/annonc/mdv298
Dey S. Preventing breast cancer in LMICs via screening and/or early detection: The real and the surreal. World J Clin Oncol. 2014;5(3):509-19. doi: 10.5306/wjco.v5.i3.509
Mittra I, Mishra GA, Dikshit RP, Gupta S, Kulkarni VY, Shaikh HKA, et al. Effect of screening by clinical breast examination on breast cancer incidence and mortality after 20 years: prospective, cluster randomised controlled trial in Mumbai. BMJ. 2021;372:n256. doi: 10.1136/bmj.n256
Iskandarsyah A, de Klerk C, Suardi DR, Soemitro MP, Sadarjoen SS, Passchier J. Psychosocial and cultural reasons for delay in seeking help and nonadherence to treatment in Indonesian women with breast cancer: A qualitative study. Health Psychol. 2014;33(3):214-21. doi: 10.1037/a0031060
Baig M, Sohail I, Altaf HN, Altaf OS. Factors influencing delayed presentation of breast cancer at a tertiary care hospital in Pakistan. Cancer Rep. 2019;2(1):e1141. doi: 10.1002/cnr2.1141
Al Shamsi H, Almutairi AG, Al Mashrafi H, Al Kalbani T. Implications of Language Barriers for Healthcare: A Systematic Review. Oman Med J. 2020;35(2):e122. doi: 10.5001/omj.2020.40
Akhtar K, Akhtar K, Rahman MM. Use of Alternative Medicine Is Delaying Health-Seeking Behavior by Bangladeshi Breast Cancer Patients. Eur J Breast Health. 2018;14(3):166-72. doi: 10.5152/ejbh.2018.3929
Somanna SN, Nandagudi Srinivasa M, Chaluvarayaswamy R, Malila N. Time Interval between Self-Detection of Symptoms to Treatment of Breast Cancer. Asian Pac J Cancer Prev. 2020;21(1):169-74. doi: 10.31557/APJCP.2020.21.1.169
World Health Organization. Operational framework for primary health care: transforming vision into action [Internet]. Geneva: World Health Organization; 2020 Aug 8. [cited 8 8 2026]. Available from: https://www.who.int/publications/i/item/9789240017832
Authors
Copyright (c) 2026 Farida Briani Sobri, Adang Bachtiar, Sonar Soni Panigoro, Dumilah Ayuningtyas, Hardya Gustada Hikmahrachim, R Cita Resti Anantia Putri, Anggindita Diah Widihidayati
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