MHA_Group 2 University of Public Health Health seeking behaviors of breast cancer patients at Yangon General Hospital & Sao San Htun General Hospital MHA_Group 2 University of Public Health

Group Members Dr Toe Maung (Leader) Dr May Zaw Tun Dr Maung Maung Win Dr Lwin Lwin Oo Dr Thidar Aung (Presenter) Dr Thida Oo Dr Su Hlaing Htwe 4/4/2020 MHA_Group 2

Introduction Breast cancer is the most frequent cancer among women. Worldwide, 2.1 million newly diagnosed female breast cancer cases in 2018 almost 1 in 4 cancer cases among women 4/4/2020 MHA_Group 2

Incidence was 6,277 (17.5 %) of all cancers in women in 2018 In Myanmar, Incidence was 6,277 (17.5 %) of all cancers in women in 2018 Death reached 2,949 or 0.75% of total death (2017) 1 of every 133 deaths (2017) Death Rate :11.51 death per 100,000 population (WHO, 2017). 4/4/2020 MHA_Group 2

Early diagnosis is the most important principle in cancer, enabling early treatment with improved outcome. To ensure early diagnosis, patient with first symptom needs to present to definitive health care provider as early as possible. 4/4/2020 MHA_Group 2

Presentation delay (Patient delay ) is defined as a prolonged interval between discovery of initial symptom to presentation to a health care provider(who can give definitive treatment ). This is usually defined as delayed presentation if this duration is more than three months. In breast cancer cases, presentation delay more than three months is associated with lower survival. 4/4/2020 MHA_Group 2

Health seeking behavior is information on time lag between the onset of illness and contacting a healthcare provider (presentation delay) type of health care provider, patient’s compliance with treatment, reasons for choice of healthcare provider, and reasons for not contacting a healthcare provider. (Akman, 2015) 4/4/2020 MHA_Group 2

Justification Breast cancer is the most common cancer and leading cause of cancer death in women If Breast cancer is localized, 5-year survival rate is 99% and 5-year relative survival rate for a specific stage of breast cancer is 90% Presentation to the definite health care provider as early as possible is important to detect breast cancer, together with prompt diagnosis and treatment 4/4/2020 MHA_Group 2

Not only the presentation but also choice of health care provider and reasons, and compliance to the treatment is vital for breast cancer patients. In Myanmar, there are studies on breast cancer risk and management but there is still a gap in health seeking behavior of breast cancer patients and this study has been conducted to fill this gap to a certain extent. 4/4/2020 MHA_Group 2

Objectives 4/4/2020 MHA_Group 2

To identify health seeking pattern of breast cancer patients General objective To elicit the health seeking behaviors of breast cancer patients at Yangon General Hospital & Sao San Htun General Hospital Specific objectives To find out the proportion of breast cancer patients with delay presentation To identify health seeking pattern of breast cancer patients To describe the factors influencing health seeking behaviors of breast cancer patients To explore the experiences and challenges in seeking health care for breast cancer 4/4/2020 MHA_Group 2

Conceptual Framework 4/4/2020 MHA_Group 2

Breast Cancer Patients Socio-demographic Characteristics Age, Education, Occupation, Marital Status, Income, Support, Residence, Lifestyle, Family History, Cultural, Family type/ structure Knowledge Screening Method Accessibility & Availability of Health Services Clinical Factors First Symptom, symptom identification & interpretation, Clinical staging, Comorbidity, Mastopathy Emotional response Fear, Depression, Anxiety Health-Seeking Behavior of Breast Cancer Patients -Presentation Delay (patient delay) -Health Seeking Pattern -Compliance of the treatment 4/4/2020 MHA_Group 2

Research Methodology 4/4/2020 MHA_Group 2

Cross-sectional hospital-based study using mixed method Study Design Cross-sectional hospital-based study using mixed method Study Area Medical Oncology and Radiation Oncology department at Yangon General Hospital and Sao San Htun General Hospital (Taunggyi) Study Period From April to May 2019 4/4/2020 MHA_Group 2

Study Population Specific Objective Study Population Exclusion Criteria To find out the proportion of breast cancer patients with delay presentation To identify health seeking pattern of breast cancer patients To describe the factors influencing health seeking behaviors of breast cancer patients Patients with breast cancer from Medical Oncology and Radiation Oncology department at Yangon General Hospital and Sao San Htun General Hospital Medical records of breast cancer patients Patients who are severely ill   4/4/2020 MHA_Group 2

Study Population Specific Objective Study Population Exclusion Criteria To explore the experiences and challenges in seeking health care for breast cancer Patients with breast cancer from Medical Oncology and Radiation Oncology department at Yangon General Hospital and Sao San Htun General Hospital Health care providers ( Surgeon, Medical oncologist, Radiation oncologist) and Health care administrator 4/4/2020 MHA_Group 2

Sample size determination n = z2pq/d2 (Daniel & Cross, 2013) where, n = sample size d = absolute precision required on either side of the proportion if confidence level=95%, z=1.96 p = proportion of presentation delay in breast cancer patients in Jordan (Abu-Helalah et al.,2016) = 0.32 q= 0.68 d= margin of error = 0.08 4/4/2020 MHA_Group 2

sample size n was calculated as follow: n=z2pq/d2 =(1.96)2*(0.32)*(0.68)/(0.08)2 =131 Minimal required sample size is 131. 4/4/2020 MHA_Group 2

Sampling Procedure Patients Quantitative 140 patients (Consecutive sampling) Qualitative Patients from Yangon General Hospital & Sao San Htun General Hospital Delay Non-Delay 4 4 4/4/2020 MHA_Group 2

For Qualitative data collection, 1 Surgeon 1 radiation oncologist Sampling Procedure Provider side For Qualitative data collection, 1 Surgeon 1 radiation oncologist 1 medical oncologist 1 health care administrator at least 6-month experience at Yangon General Hospital and Sao San Htun General Hospital 4/4/2020 MHA_Group 2

Data Collection Methods and Tools Objectives Data Collection methods and Tools Sample Size -To find out the proportion of breast cancer patients with delay presentation -To identify health seeking pattern of breast cancer patients -To describe the factors influencing health seeking behaviors of breast cancer patients - Face to face interview with structured Questionnaires -Patient’s Medical Record 140 4/4/2020 MHA_Group 2

Data Collection methods and Tools Sample Size Objectives Data Collection methods and Tools Sample Size - To explore the experiences and challenges in seeking health care for breast cancer In-depth interview (IDI) with Interview guidelines - Key informant interview (KII) with Interview guidelines 8 4/4/2020 MHA_Group 2

Data management and analysis Quantitative data Analysis : For data entry, Epi-data was used to avoid missing data, to ensure skip pattern, to ensure possible range. Checking (Consistency, range) was done using SPSS. Descriptive statistics on respondents background characteristics, socio-economic characteristics. The summary measures for continuous variables and frequency and percent for categorical variables were calculated. 4/4/2020 MHA_Group 2

Qualitative Data Analysis For qualitative study, recordings of the interviews were transcribed into text (transcripts) in exactly the same words (verbatim) as in the interviews Pre-test was done at North Okkala General Hospital. A total of 10 respondents 1 Health Care Provider (Medical Oncologist) 1 Health Care Administrator 4/4/2020 MHA_Group 2

Ethical Consideration The study was conducted according to the guidelines issued by UPH-IRB(2019/MHA-G/1) Written informed consents were obtained from the respondents. Privacy and confidentiality of the collected information was strictly safeguarded. 4/4/2020 MHA_Group 2

Findings 4/4/2020 MHA_Group 2

56 patients from Yangon region, 31 patients from Shan state Catchment area of breast cancer patient Out of 140 respondents, 56 patients from Yangon region, 31 patients from Shan state Remaining from other states and regions 4/4/2020 MHA_Group 2

Quantitative Findings Background characteristics of respondents 33% - each in 40-49 year and 50-59 year age group 60% - married 54% - lived in Urban 33% - primary school level 56% - dependent 61% - nuclear type family 83% - have financial hardship for treatment 4/4/2020 MHA_Group 2

Sources of financial support *(n=140) Figure5.2.Sources of financial support *(n=140) 4/4/2020 MHA_Group 2

Lifestyle of the respondents (n=140) Figure 5.3. Lifestyle of the respondents (n=140) 4/4/2020 MHA_Group 2

Distribution of co-morbidity of the respondents* (n=140) Figure 5.4. Distribution of co-morbidity of the respondents (n=140) *Multiple response 4/4/2020 MHA_Group 2

Distribution of previous mastopathy of the respondents (n=140) Mastitis, 27% No Breast Abscess 8% Previous Mastopathy 19% FA Breast 58% Benign Breast lump 8% Figure 5.5. Distribution of previous mastopathy of the respondents (n=140) 4/4/2020 MHA_Group 2

Figure 5.6. Distribution of noticing someone with breast cancer among the respondents (n=36) 4/4/2020 MHA_Group 2

Figure 5.7. Distribution of the knowledge on symptoms of breast cancer among respondents *Multiple response 4/4/2020 MHA_Group 2

Figure 5.8. Distribution of the knowledge on screening methods for breast cancer among the respondents *Multiple response   4/4/2020 MHA_Group 2

Self-breast examination 85.7% Mammogram 7.1% Breast USG 7.1% Figure 5.9. Distribution of screening test done 5 years prior to the disease among the respondents (n=14) 4/4/2020 MHA_Group 2

Figure 5.10. Sources of health information for Breast Cancer among the respondents *Multiple response 4/4/2020 MHA_Group 2

Reported follow-up status of the respondents (n=140) 90% reported that they had regular follow-up. 4/4/2020 MHA_Group 2

38% had delayed presentation Delayed presentation in breast cancer patients 38% had delayed presentation 4/4/2020 MHA_Group 2

Delayed presentation in breast cancer patients Figure 5.12 Patient delay in breast cancer patients (n=140) 4/4/2020 MHA_Group 2

Figure5.13.Health Seeking Pattern of Breast Cancer Patients (n=140) . 4/4/2020 MHA_Group 2

Figure 5.14. Decision maker for taking treatment in relation to delayed presentation (n=140) * p=0.054   4/4/2020 MHA_Group 2

Figure5.15 . Factors influencing Health Seeking Behaviour of breast cancer patients with delayed presentation 4/4/2020 MHA_Group 2

Non-delay Delay p-value n (%) Early stage (1+2) 61 (70.9) 25 (29.1)   Non-delay Delay p-value n (%) Early stage (1+2) 61 (70.9) 25 (29.1) 0.014*  Late stage (3+4) 21 (48.8) 22 (51.2) Figure 5.16 Patient delay in breast cancer patients according to tumor-staging (n=129)   4/4/2020 MHA_Group 2

Figure 5.17 Patient delay in breast cancer patients by emotional response to first symptom (n=140) 4/4/2020 MHA_Group 2

Percent   50 4.6 6.2 4.1 2.0 Figure.5.18 Respondents Reasons for Presenting Late for health-seeking (n=53) 4/4/2020 MHA_Group 2

Qualitative Findings 4/4/2020

Characteristics of IDI respondents No Age(Years) Education Occupation Marital Status 1 39 Higher Seller Married 2 70 B.Ed. Pension Single 3 57 Primary Farmer Widow 4 37 Middle 5 72 Penson 6 54 Dependence 7 48 Illiterate 8 38 AGTI Check font size 4/4/2020

Characteristics of KII respondents No. Age (Years) Rank Total Service (Years) Service years at Current Rank(Years) 1. 52 Senior M.S 23 1 2. 46 M.S 19 3 3. S.C (Surgeon) 24 4. 42 J.C(Surgeon) 15 4 5. 45 J.C (Medical Oncologist) 18 6 6. 33 Specialist A.S(Medical Oncologist) 7 7. 44 S.C (Radiation Oncologist) 16 8. S.C(Radiation Oncologist) 4/4/2020

Themes Seeking treatment for breast cancer Perception towards breast cancer treatment Perception towards adjuvant therapy in breast cancer treatment Reason for delayed presentation Sources of information about breast cancer Suggestions 4/4/2020

1. Seeking treatment for breast cancer လက္သည္းခြံေလာက္ အက်ိတ္ရွိတာက စၿပီး ရင္သားကင္ဆာ လကၡဏာကို စသိခဲ့ပါတယ္။ စသိၿပီးတာနဲ႔ ခ်က္ခ်င္း ဆရာ၀န္ သြားျပတာ ေပါ့ေနာ္။ ေနာက္ (၂) ရက္ပဲ ခ်က္ခ်င္းခြဲထုတ္ လိုက္တာေပါ့။ 38years,graduated,non-delayed presentation

အက်ိတ္ေလးေပၚလာတာ ၄၊၅၊၆လေလာက္ရွိေတာ့မွ ဆရာ၀န္နဲ ့ သြားျပျဖစ္တာေပါ့။ ေဆးထိုးျပီး၊ ေဆး၁လစားတာ။ အကိ်တ္ကေတာ ့ေလ်ာ့မသြားဘူး၊ ဒါေပမဲ့ ထပ္သြားမျပေတာ့ဘူး။ ေနာက္တစ္က်ိတ္ထပ္ထြက္လာမွပဲ ခြဲျဖစ္သြားတာ။ ပထမေတာ့ရိုးရိုးပဲထင္တာ ေနာက္ေတာ့ လက္ကက်ဥ္လာတယ္ နို ့ကလည္း ပုံပ်က္လာတယ္ ၊ အဲဒါ ကင္ဆာ ပဲဆိုျပီးေတြးမိလိုက္တယ္။ အဲ့က်မွသြားျပျဖစ္တယ္ 72yrs,graduated,delayed presentation  

45yrs, 4yrs & 3 months service at current post, Radiation Oncologist လူနာအမ်ားစုဟာ အဆင့္ ၂ - ၃ ေလာက္ရွိတယ္။ ။ အနည္းစုက Stage IV, secondary- Lung, brain နဲ႔ လာၾကတယ္။ early stage နဲ႔လာတာ ရွားတယ္။ အမ်ားစုကေတာ့ advanced stage ေတြပဲ လာတတ္ၾကတယ္။ 45yrs, 4yrs & 3 months service at current post, Radiation Oncologist

2. Perception towards breast cancer treatment ေစာစီးစြာ ခံယူသင့္ပါတယ္။ ကုသရင္လဲ ေပ်ာက္ကင္းႏိုင္ပါတယ္။ ရင္သားကင္ဆာကို ေစာစီးစြာ သိႏိုင္ဖို႔က လူနာဘက္က ကိုယ့္ရင္သားကို စမ္းသပ္စစ္ေဆးေနဖို႔ လိုပါတယ္။ အဲဒီအတြက္လဲ ပညာေပးဖို႔ လိုပါမယ္။ 70 yrs, graduated, non-delayed presentation

3. Perception towards adjuvant therapy in breast cancer treatment 4/4/2020 MHA_Group 2

4. Reason for delayed presentation Sub-themes Not knowing “ေဆးၿမီးတိုနဲ႔ ကုလိုက္လို႔ ရွိရင္ ဒီလိုအက်ိတ္ဆိုေတာ့ အနာပြင့္သြားမယ္။ ေပ်ာက္သြားမယ္လုိ႔ ထင္တာေပါ့ ေလ။ အထဲက အခဲေလး ေတြ ထြက္သြားေတာ့ အနာစိမ္းလိုေပါ့ေနာ္။ အဲလို ထင္ၿပီးကုၾကတာ။” (38years, graduate, non-delayed presentation) Financial barrier “ဆရာမကေတာ့ေျပာပါတယ္။ ေငြေၾကးမကုန္ဘူးတဲ့။ ဒါေပမဲ့ စားစရိတ္၊ သြားစရိတ္ ေတြကလဲ ကုန္တယ္ေလ စုစုေပါင္း ကုန္က်စရိတ္က သိန္း(၃၀)ေက်ာ္ၿပီေလ။ ေဆးကုသစရိတ္က (၁၀) သိန္းေက်ာ္ေလာက္ပဲ ကုန္ပါတယ္။” (42yrs, illiterate, non-delayed presentation) Check Myanmar font size Financial barrier- insert treatment cycle 4/4/2020

4. Reason for delayed presentation Sub-themes Emotional barrier “ေဆးသြင္းရင္ မခံႏုိင္မွာတုိ႔၊ ဓာတ္ကင္ရင္ ေသမွာလုိ႔ ေျပာၾကေတာ့ ေၾကာက္တာေပါ့ ဆရာမရယ္။” (57 years, primary school passed, delayed presentation) Social barrier “ေဆး႐ံုကို သြားျပရတာ။ …….. လူနာေစာင့္အခက္အခဲလည္း ရွိတယ္။” (54 years, primary school passed, delayed presentation) Check Myanmar font size Financial barrier- insert treatment cycle 4/4/2020

5.Sources of information about breast cancer Half of respondents told that they got information from flyers and pamphlets from hospitals and clinics and explanations by health care providers only when they had disease and took treatment from that place. One respondent told that she never got any pamphlet from clinic/ hospital. Minority of respondents revealed that they got information from multi-media including TV. About one-third of respondents said that they obtained information from their surroundings/environments. 4/4/2020

6.Suggestions Health Education About three out of eight women emphasized that health education to people should be provided. Some key informants suggested that health education should be provided at the grass-roots level Drug Supply Some women suggested that drug supply for chemotherapy, donation for supplementary food and drug for breast cancer patients should be done. Waiting time Only One woman wanted that waiting time for radiotherapy should be shorter . 4/4/2020

6.Suggestions Screening and regular check-up One health care provider suggested that every woman should regularly do screening every 6 month in order to obtain early treatment and prevention. Development of multi-disciplinary team and standard guideline Many health care providers suggested that there should be multi-disciplinary team and standard guideline for breast cancer patient in Myanmar. 4/4/2020

Discussion 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Background characteristics Majority- Married In Ghana study: Similar finding (Ofori, 2015) In Pakistan study: Vast majority- married (Gulzar et al., 2019) Half- Primary & middle school level In Estonia study, more than half- secondary school level (Innos et al., 2013) 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Delayed presentation among breast cancer patients 38%- Delayed In Pakistan study : 39% (Gulzar et al., 2019) In Germany study : 18% (Arndt et al., 2002) In Estonia study : 17% (Innos et al., 2013) In Thailand study : 17% (Poum et al., 2013) Most common delayed age group 40-59 year old (40%) In Uganda study, 35-44 year old group (Odongo et al., 2015) In Estonia study, over 65 year old group (47%) (Innos et al., 2013) 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Health seeking pattern of breast cancer patients 58%- first visited hospital & clinic In Ghana study: 31% - first visited hospital & clinic, (Ofori, 2015) Factors influencing health seeking behavior of breast cancer patients 38%- Comorbidity Patients with comorbidity- lower delayed presentation In Germany study: 61% (Arndt et al., 2002) In South Africa study: Similar pattern (Joffe et al., 2018). 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Factors influencing health seeking behaviour of breast cancer patients 19%- Previous mastopathy Patients with mastoapthy- higher delayed presentation (not significant) In Germany study, 25% (Arndt et al., 2002) In Germany and Iranian studies, similar pattern (not significant) (Arndt et al., 2002) In Estonia, similar pattern( statistically significant) (Innos et al., 2013) 16%-Family History Patients with family history-lower delayed presentation In Pakistan study, 17% (Gulzar et al., 2019) In Germany study, 13% (Arndt et al., 2002) In Pakistan study, contrary pattern (s significant) (Gulzar et al., 2019) IN Germany study, similar pattern( not significant) 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Factors influencing health seeking behavior of breast cancer patients 14%- Regular self breast exam Patients with regular SBE- lower delayed presentation (not significant) In Germany study, 53% (Arndt et al., 2002) In Germany, similar pattern (not significant) (Arndt et al., 2002) 10%-Breast Cancer screening ( 5 yrs) Patients with Breast Ca screening-higher delayed presentation In Ghana study, 24% (Ofori, 2015) In Germany study, 72% (Arndt et al., 2002) In Ghana study, similar pattern (s significant) (Ofori, 2015) In Germany study, different pattern (not significant) (Arndt et al., 2002) 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Factors influencing health seeking behaviour of breast cancer patients 94%- presented with breast lump as first symptom In Iranian study, 86% (Montazeri et al., 2003) In Estonia study, 77% (Innos et al., 2013) In Germany study, 67% (Arndt et al., 2002) 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Factors influencing health seeking behaviour of breast cancer patients 70%-Early Stage 30%-Late Stage Patients in Late Stage-higher delayed presentation (Statistically significant p=0.01) In Uganda and South African studies, similar pattern (Statistically significant) (Odongo et al., 2015) (Joffe et al., 2018). Source of information on Breast cancer More than half- from their families and friends Role of multimedia (TV, FM channels ) in providing health information is still limited In Germany study, 53% in Early stage and 47% in Late stage 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Factors influencing health seeking behavior of breast cancer patients Patients who felt worried and feared to initial symptom- lower delayed presentation (Statistically significant p=0,001) Myanmar women with breast cancer symptom who were worried and feared of their breast cancer becoming a serious disease presented early to definitive health care providers >50%-made decision by herself Decision maker to take treatment (herself)- lower delayed presentation (p=0.05) In Ghana study, husband- 46% (Ofori, 2015) 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Reasons for delayed presentation 50%- Patients did not think their symptoms/ disease as cancer and as being important 15%- Financial problem as their reason for delayed presentation In South Africa study, 30% (Joffe et al., 2018). In Germany study, 55% (Arndt et al., 2002) In Ghana study, 24% (Ofori, 2015) 4/4/2020 MHA_Group 2

Discussion: Comparison/ Explanation/ Implication In this study Discussion: Comparison/ Explanation/ Implication Comparison/ Explanation/ Implication Reasons for delayed presentation From qualitative aspect, not knowing diseases, financial barrier, emotional barriers (shyness for presentation to health care provider and fear of radiation and chemotherapy), social barriers (such as lack of attendance and absence from work). In Ghana and Iranian study, similar finding (Ofori, 2015) (Montazeri et al., 2003) 4/4/2020 MHA_Group 2

Conclusion

Major reasons for delayed presentation Delayed presentation to the first definitive health care providers = 37.9% Major reasons for delayed presentation From quantitative aspect, not recognize their first symptom as being cancer (50%) facing financial problems (15%) From qualitative aspect, not knowing diseases financial barrier emotional barriers (shyness for presentation to health care provider and fear of radiation and chemotherapy) social barriers (such as lack of attendance and absence from work) 4/4/2020

The higher the staging, the more delayed presentation (p= 0.014) First point of seeking healthcare  31% relied on the government hospitals Women who were worried and feared about their first symptom were less likely to present late (20%) The association between emotional feeling for their first symptom and delayed presentation is statistically significant. (p= 0.001) The higher the staging, the more delayed presentation (p= 0.014) 32% decide themselves for seeking health care Association between decision maker for seeking health care and delayed presentation is not so strong (p=0.05) 4/4/2020

From both quantitative and qualitative points of view, Family members and friends - main source of health information on breast cancer Role of multimedia (TV and FM channel) in providing health information still limited 4/4/2020

Recommendations 4/4/2020 MHA_Group 2

Early breast cancer symptoms To include the following messages related to breast cancer in health education session, counseling and training: Early breast cancer symptoms Consulting with definitive health care provider as early as possible Regular breast self-examination To expand health information on breast cancer through multimedia channels (FM channel, TV) To encourage future research on diagnosis and treatment delay in breast cancer patients in Myanmar 4/4/2020

Operational definition 4/4/2020 MHA_Group 2

Health seeking behavior: a sequence of remedial actions that individuals undertake to cure perceived ill health Presentation delay/ Patient delay : a prolonged interval between discovery of initial symptom to presentation to a health provider(who can give definitive treatment ) and in this study it has been defined as ≥3 months. 4/4/2020 MHA_Group 2

References 4/4/2020 MHA_Group 2

com/myanmar-breast-cancer>. Anon n.d. Breast Cancer in Myanmar. Available at: <https://www.worldlifeexpectancy. com/myanmar-breast-cancer>. Anon n.d. Cancer rising in Myanmar - Global New Light Of Myanmar. Barbor, M., n.d. Global Burden of Cancer on the Rise: Implications for Cancer Prevention and Control. the Asco post. Pecific, I., Country-specific, M., Lung, B., Colorectum, S., Cervix, L.S., Liver, B., Computed, P. and Index, H.D., 2019. 53 855 731. 692, pp.2018–2019. world health organization, 2018. WHO | Breast cancer. Who. 4/4/2020 MHA_Group 2

Pushpalata, N. and Chandrika, K. B. , 2017 Pushpalata, N. and Chandrika, K.B., 2017. Health care seeking behavior – A theoretical perspective. Paripex Indian Journal of Research, 6(1), pp.790-792. Naz, M.S.G., Simbar, M., Fakari, F.R. and Ghasemi, V., 2018. Effects of Model-Based Interventions on Breast Cancer Screening Behavior of Women: a Systematic Review. Asian Pacific Journal of Cancer Prevention, [online] 19(8), pp.2031–2041. Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6171373/ pdf/APJCP-19-2031.pdf>. 4/4/2020 MHA_Group 2

Ströbele, L. , Kantelhardt, E. J. , Traoré Millogo, T. F. D Ströbele, L., Kantelhardt, E.J., Traoré Millogo, T.F.D., Sarigda, M., Wacker, J. and Frie, K.G., 2018. Prevalence of breast-related symptoms, health care seeking behaviour and diagnostic needs among women in Burkina Faso. BMC Public Health, 18(1), pp.1–7. Barnard ME, Boeke CE, Tamimi RM. Established breast cancer risk factors and risk of intrinsic tumor subtypes. Biochim Biophys Acta. 2015;1856: 73-85. Bray, F., 12 September 2018. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians, 68(6), pp. 394-424. 4/4/2020 MHA_Group 2

THANK YOU 4/4/2020 MHA_Group 2